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Preface
Vitreoretinal surgery demands a high level of both manual precision and mental
clarity. It’s a eld where miracles can be created to bring light and hope to darkness
and desperation. For retina surgeons, mastering vitreoretinal surgery requires a long
learning process, a steep learning curve, and the ability to shoulder immense responsibility. Yet, it is also a eld lled with obstacles and challenges, while bringing a
unique sense of professional accomplishment.
Over the past century, vitreoretinal surgery has undergone tremendous development. What was once regarded as an inaccessible and uncertain territory has gradually become a mature surgical discipline due to the rened instruments, improved
visualization systems, and increasingly sophisticated surgical concepts. Many pioneers devoted their lives to exploring this eld, despite the conditions being far less
favorable than we enjoy today. Their perseverance transformed the treatment of retinal diseases from an uncertain attempt into a reliable and effective surgical practice.
Despite the achievements up till now, vitreoretinal surgery remains the Benben
stone of the pyramid of ophthalmology. The eye is a delicate and complex organ,
offering the narrow connes of the vitreous cavity and unstable intraocular environments for retinal surgeons to repair the fragile tissues. Each case is quite unique, and
the surgeon is required to make decisions before, during, and after surgery. In such
circumstances, technique alone is inadequate.
Many young surgeons begin their training by memorizing surgical steps. They
learn how to set up the machine, where to place the trocars, how to perform uid–air
exchange, and how to apply laser photocoagulation. These steps are necessary but
not sufcient. When facing unexpected situations—an undetected retinal break, a
sudden hemorrhage, or an unstable intraocular pressure—repetition of standard procedures will not get you out of the trap. At that moment, only a clear understanding
of the underlying logic can guide the surgeon forward.
The essence of vitreoretinal surgery is not a sequence of movements, but a way
of thinking. Each surgical maneuver is a response to the physical, anatomical, and
pathological conditions inside the eye. The behavior of uids, the elasticity of tissues, and the interaction between instruments and intraocular structures all follow
certain principles. If these principles are understood, the surgery becomes logical
and coherent. If ignored, even the skillful hands may encounter unnecessary
difculties.
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Preface
During years of clinical practice and teaching, we have observed that many trainees struggle not because of their lack of diligence, but because of their lack of
understanding of the underlying principles. They could perform well in routine
cases, but may get stuck when conditions deviate from the expected pattern.
This book, coauthored by two experienced retina surgeons from China and
Europe, is born from a conviction that the advancement of surgical care thrives on
the synthesis of diverse experiences, philosophies, and techniques. It represents a
deliberate effort to bridge geographical and methodological perspectives, bringing
together the rich, evolving narrative of vitreoretinal surgery in China with the established and innovative practices from Europe.
We hope to present vitreoretinal surgery as an integrated discipline, in which
theory and practice are inseparable. Each chapter attempts to answer not only the
question of how a procedure is performed, but also why it should be performed. By
understanding the reasoning behind each step, the reader may develop the ability to
adapt to different situations and to make sound surgical decisions.
Another important intention of this book is to promote the exchange of surgical
experience across different regions. Vitreoretinal surgery has developed along
diverse paths due to variations in training systems, different clinical environments
and technological resources, which have led to different surgical philosophies and
techniques. These differences should not be considered as contradictions, but as
valuable sources of knowledge.
This book brings together experiences from both China and Europe. By presenting these perspectives side by side, we hope to provide readers with a broader
understanding of vitreoretinal surgery. Exchanging clinical experiences is particularly important in the current epoch, when scientic communication is no longer
limited by geography. The progress of medicine depends on openness, collaboration, and the willingness to learn from one another.
The rst part of this book focuses on the conceptual foundations and practical
principles of vitreoretinal surgery. It begins with the historical development and the
contributions of major pioneers. It then introduces the physical principles that govern intraocular surgery, the evolution and characteristics of tamponade agents, and
essential aspects of preoperative evaluation. Subsequent chapters discuss common
surgical conditions, including retinal detachment, proliferative diabetic retinopathy,
epiretinal membrane, macular hole, and proliferative vitreoretinopathy. Special
attention is given to challenging situations and pediatric cases, where careful judgment is especially important.
Recognizing the growing importance of digital communication, a chapter is also
devoted to the editing and sharing of surgical videos. Currently, surgical videos have
become an essential medium for education and academic communication in ophthalmology. Learning how to present surgical work clearly and responsibly is of
great importance during a surgeon’s professional development.
Preface
xv
The second part of the book presents vitreoretinal techniques and experiences
from Europe. These chapters illustrate different approaches to both routine and
complex surgeries, offering readers alternative perspectives and practical insights.
By comparing different strategies, surgeons may better understand the strengths and
limitations of each approach and make adaptations based on their own clinical
environments.
This book is the brainchild of close collaboration among colleagues from different countries. Such cooperation reects the spirit of modern medicine, where
knowledge is shared across borders for the benet of patients worldwide. We are
deeply grateful to all contributors who generously shared their experience
and wisdom.
We also acknowledge the mentors who guided us at the beginning of our surgical
careers. Their patience, strictness, and encouragement shaped our professional attitudes and surgical habits. Above all, we thank all our patients. Each surgical
improvement, every new technique, and every lesson learned in the operating room
ultimately come from the trust they place in us.
Vitreoretinal surgery is a lifelong journey. It requires not only technical skill, but
also perseverance, humility, and continuous learning. Techniques will change,
instruments will improve, and concepts will evolve. But the fundamental principles—respect for tissue, careful observation, rational decision-making, and responsibility toward patients—will remain eternal.
If this book helps young surgeons understand these principles more clearly,
approach surgery with greater condence, and avoid unnecessary mistakes, its purpose will have been achieved.
Vitreoretinal surgery will continue to advance, and future generations will
undoubtedly surpass what has been accomplished today. We hope this book will
serve as a small step along this path, contributing to the shared goal of preserving
and restoring vision.
Finally, we would like to express our gratitude to Yuntong Li, Wenjia Yan,
Yangming Xu, Baizhou Chen, and Shudi Mao for their great help in organizing
the book.
xvi
Preface
Guangzhou, China ZhaotianZhang
Uppsala, Uppsala Län, Sweden UlrichSpandau
Competing Interests
The authors have no competing interests to declare that are relevant to the content
of this manuscript.
xvii
Contents
Part I Basics of Vitreoretinal Surgery
1 A Brief History of the Development of Vitreoretinal Surgery 3
1.1 The Evolution of Treatment Eras for Rhegmatogenous
Retinal Detachment 3
1.1.1 Pre-Jules Gonin Era 3
1.1.2 Post-Jules Gonin Era 5
1.2 The Evolution of Retinopexy Methods 6
1.3 The Development of Scleral Buckling 6
1.4 The Development of Modern Vitrectomy 8
1.5 The Continuous Improvement of Vitreoretinal Surgery 9
1.6 Summary 11
2 Physical Principles Underlying Vitreoretinal Surgery 13
2.1 Bernoulli’s Principle 13
2.2 Hydrostatic Pressure in Fluids 15
2.3 Poiseuille Equation 16
2.4 Surface Tension and Interfacial Tension 17
2.4.1 Surface Tension 17
2.4.2 Interfacial Tension 18
2.4.3 The Manifestation of Surface/Interfacial Tension
2.4.4 The Relationship Between Interfacial Tension
2.5 Boyle’s Law 20
2.6 Fick’s Diffusion Law 22
2.7 Other Physical Principles 23
2.8 Summary 23
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in Intraocular Tamponade Agents 18
and Retinal Reattachment 19
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3 Intraocular Tamponade Agents 25
3.1 The Evolution of Intraocular Tamponade Agents 25
3.2 Common Physical Properties of Intraocular Tamponade Agents 26
3.2.1 Density 26
3.2.2 Buoyancy 26
3.2.3 Interfacial Tension 27
3.2.4 Viscosity 28 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Contents
3.3 Gases 29
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3.3.1 Function and Metabolism of Gases 29
3.3.2 Pneumatic Retinopexy 29
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3.3.3 Other Indications for Gas Tamponade 32
3.3.4 Gas Injection Techniques 32
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3.3.5 Precautions when Preparing for and Performing
Intravitreal Gas Injection 33
3.3.6 Precautions After Intravitreal Gas Injection 34
3.4 Silicone Oil 39
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3.4.1 Physical and Chemical Properties 39
3.4.2 Silicone Oil Usage Rate 39
3.4.3 Effects and Indications of Silicone Oil Tamponade 40
3.4.4 Techniques of Silicone Oil Injection 41
3.4.5 Complications and Management of Silicone Oil 43
3.5 Heavy Liquid 53
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3.5.1 Physical and Chemical Properties 53
3.5.2 Indications and Usage of Heavy Liquid 54
3.5.3 Indications and Effects of Heavy Liquid 55
3.5.4 Injection and Drainage of Heavy Liquid 58
3.6 Summary 61
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Part II Vitrectomy in China
4 Preoperative Preparation and Anesthesia 65
4.1 Doctor-Patient Interaction 65
4.2 Preparation of the Surgeon 66
4.3 Choice of Anesthesia 69
4.3.1 Local Anesthesia 70
4.3.2 General Anesthesia 74
4.4 Summary 74
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5 Basic Steps and Techniques of Vitrectomy 75
5.1 Common Terms and Instruments 75
5.1.1 Instrument Diameter 75
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5.1.2 Trocar-Cannula System 75
5.1.3 Vitrectomy Machine 77
5.2 Basic Steps 77
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5.2.1 Selection of PPV 77
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5.2.2 Basic Objectives of PPV 78
5.2.3 Basic Operation of PPV 78
5.3 Practical Skills and Detailed Illustration 83
5.3.1 Creation of Scleral Incision 83
5.3.2 Safety of the Perfusion Line 87
5.3.3 Posterior Vitreous Detachment (PVD) 88
5.3.4 Safe Removal of Sufcient Vitreous 95
5.3.5 Common Mistakes in Light Pipe Operation 96
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Contents
xxi
5.3.6 How to Perform Scleral Indentation Well 97
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5.3.7 Understanding the Safe Operation of Intraocular
Instruments from a Geometric Perspective 98
5.4 Summary 99
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6 Surgical Intervention of Rhegmatogenous Retinal Detachment:
Part 1 (Scleral Buckling) 101
6.1 Current Status of Scleral Buckling 101
6.2 Indications for Scleral Buckling 102
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6.2.1 Pathological Mechanism of Rhegmatogenous Retinal
Detachment 103
6.2.2 Functions of Scleral Buckling 105
6.2.3 Indications for Scleral Buckling 105
6.2.4 Relative Contraindications for Scleral Buckling 110
6.3 Preoperative Break Localization for Scleral Buckling 110
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6.3.1 Emphasize the Application of Three-Mirror Lens
Examination 110
6.3.2 Lincoff’s Rules 111
6.4 Basic Steps and Precautions of Scleral Buckling 113
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6.4.1 Understand Different Philosophies of Scleral Buckling 113
6.4.2 Basic Steps of Scleral Buckling 113
6.5 Different Operations in Scleral Buckling 122
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6.5.1 Break Localization and Sealing Under Indirect
Ophthalmoscope and Microscopes 122
6.5.2 Subretinal Fluid Drainage 123
6.5.3 Scleral Encircling 126
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6.5.4 Modied Methods in Scleral Buckling 127
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6.5.5 Modied Suturing Technique to Produce Temporary
Scleral Buckling Effect for Noncomplex
Rhegmatogenous Retinal Detachment 128
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6.6 Postoperative Complications and Management of Scleral Buckling 130 . .
6.6.1 Persistent Subretinal Fluid 130
6.6.2 Recurrent Retinal Detachment 131
6.6.3 Elevated Intraocular Pressure 131
6.6.4 Anterior Segment Ischemia 132
6.6.5 Explant Displacement and Extrusion 133
6.6.6 Extraocular Muscle Dysfunction 133
6.6.7 Refractive Changes 133
6.6.8 Common Issues of Retinal Detachment 134
6.7 Summary 134
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7 Surgical Intervention of Rhegmatogenous Retinal Detachment:
Part 2 (Pars Plana Vitrectomy) 135
7.1 Patient Selection for Vitrectomy 135
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7.2 Why You Should Be Familiar with the Underlying Logic
of Parameters Settings on Vitrectomy Machine 136
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Contents
7.3 Fundamental Steps and Key Precautions 137
7.3.1 Cutting Central Vitreous 137
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7.3.2 Conrming or Creating Posterior Vitreous Detachment 138
7.3.3 Relieving Traction on Primary Retinal Breaks 138
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7.3.4 Examination of the Peripheral Retina (Generally
Performed Simultaneously with Step 5) 139
7.3.5 Removing Peripheral Vitreous 139
7.3.6 Reattaching the Retina 140
7.3.7 Sealing Retinal Breaks 140
7.3.8 Intraocular Tamponade Agents 142
7.3.9 Adjusting Intraocular Pressure 143
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7.3.10 Closing Scleral Incisions and Advising the Patient
to Maintain a Face-Down Position 143
7.4 Details of Air/Fluid Exchange 143
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7.4.1 Advantages and Disadvantages 143
7.4.2 Key Points and Difculties 144
7.4.3 Application of Flute Needle 145
7.4.4 Cooperation of Patient’s Head Position and Eye Position 147
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7.5 Systematic Approach to Prevent Inadvertent Perfusion in Eyes
with Extensive Choroidal Detachment, Suprachoroidal Fluid,
and Hypotony During Pars Plana Vitrectomy 148
7.6 Etiology and Surgical Treatment of Giant Retinal Tear 151
7.6.1 Pathological Basis 151
7.6.2 Surgical Principles 151
7.6.3 Surgical Strategies 153
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7.7 Surgical Treatment of Retinal Detachment Secondary
to or Concomitant with Macular Hole 155
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7.8 How to Modify the Surgical Approach When Primary Break(s)
Cannot Be Found 158
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7.9 Additional Steps to Ensure Possibly Higher Long-Term
Reattachment Rate 159
7.9.1 360° Laser Encircling 159
7.9.2 Scleral Buckling 159
7.10 Surgical Complications and the Management 161
7.11 Summary 161
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8 Surgical Management of Diabetic Retinopathy 163
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8.1 Underlying Logic for Surgeons to Better Understand Surgical
Techniques 163
8.1.1 Retinal Proliferative Changes 164
8.1.2 Vitreous Status 165
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8.2 How to Better Analyze Dilemmas when Surgical Intervention
Is the Only Option 166
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8.2.1 Signicant Discrepancy Between Preoperative
and Intraoperative Findings 167
8.2.2 A Fine Line Between Treatment and Harm 167
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Contents
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8.2.3 Coordination of Interventional Strategies 167
8.3 When to Use Anti-VEGF 168
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8.4 Surgical Treatment of Vitreous Hemorrhage 170
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8.4.1 Diagnostic Evaluation and Etiology of Vitreous
Hemorrhage 170
8.4.2 Timing of Surgery for Vitreous Hemorrhage 171
8.4.3 Surgical Techniques and Intraoperative Precautions 172
8.4.4 Management of Postoperative Recurrent Hemorrhage 176
8.5 Techniques for Relieving Vitreoretinal Traction 177
8.5.1 Segmentation Technique 178
8.5.2 Delamination Technique 178
8.5.3 En Bloc Technique 180
8.6 Vital Dyes and Intraocular Tamponade Agents 180
8.6.1 Staining Agents 180
8.6.2 Tamponades 182
8.7 How to Get Rid of Intraoperative Dilemmas 184
8.7.1 Corneal Edema 184
8.7.2 Lens Opacity 184
8.7.3 Pupillary Constriction 184
8.7.4 Iatrogenic Retinal Tears 185
8.7.5 Intraoperative Bleeding 185
8.8 Postoperative Complications and the Management 187
8.8.1 Elevated Intraocular Pressure 187
8.8.2 Uveal Reaction and Inammation 187
8.8.3 Lens Opacity 188
8.8.4 Iris Neovascularization and Secondary Glaucoma 188
8.8.5 Anterior Hyaloidal Fibrovascular Proliferation 188
8.8.6 Intraocular Fibrin Syndrome 189
8.8.7 Vitreous Hemorrhage 189
8.9 Summary 191
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9 Surgical Management of Epiretinal Membrane 193
9.1 Clinical Characteristics 193
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9.1.1 Classication and Etiology of ERM 193
9.1.2 Staging of Idiopathic Epiretinal Membrane 194
9.2 Etiology of Epiretinal Membrane 195
9.2.1 Cellular Components of ERM 196
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9.3 Evaluation and Differential Diagnosis 197
9.4 Surgical Timing and Prognostic Factors 198
9.4.1 Surgical Timing 198
9.4.2 Prognostic Factors 200
9.5 Standard Surgical Steps 201
9.6 Use of Vital Dyes 202
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9.6.1 Triamcinolone Acetonide (TA) 202
9.6.2 Indocyanine Green (ICG) 203
9.6.3 Brilliant Blue G (BBG) 204
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