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xxiv
Contents
9.7 Underlying Logic and Practical Skills of Membrane Peeling 204
9.7.1 Preparation 204
9.7.2 Flap Initiation Methods 207
9.7.3 Expanding the Flap 209
9.7.4 Deciding Whether to Peel the ILM 209
9.8 Complications 209
9.8.1 Intraoperative Complications 209
9.8.2 Postoperative Complications 210
9.9 Summary 211
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10 Surgical Intervention of the Macular Hole 213
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10.1 How Macular Hole Became a Curable Disease: Lessons
for Surgeons 213
10.2 Classication and Staging of MH 215
10.2.1 Classication 215
10.2.2 Staging of Idiopathic Macular Hole (IMH) 215
10.3 Etiology of Macular Hole 217
10.4 Routine Surgical Procedures 218
10.5 Use of Dyes 219
10.5.1 Commonly Used Dyes 219
10.5.2 Modied Approaches to ILM Staining 220
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10.6 Underlying Logic and Practical Skills of Internal Limiting
Membrane Peeling 222
10.6.1 Challenges for Novice Surgeons 222
10.6.2 Flap Initiation Techniques 224
10.6.3 Extending the ILM Flap 225
10.6.4 ILM Flap Techniques 228
10.7 Complications 228
10.8 Summary 229
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11 Prevention and Management of Proliferative Vitreoretinopathy 231
11.1 Etiology 231
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11.1.1 Cell Composition of Proliferative Vitreoretinopathy 231
11.1.2 Regulation of Cell Proliferation and Migration 232
11.1.3 Extracellular Matrix Remodeling 233
11.1.4 Susceptibility Genes 233
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11.2 Clinical Classication and Staging of PVR 233
11.2.1 Clinical Manifestations 233
11.2.2 Grading 237
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11.3 Risk Factors of Occurrence and Development of PVR 237
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11.4 Surgical Strategies for Improving Long-Term Outcomes
in Severe PVR 240
11.4.1 Identication and Release of Preretinal Proliferation 240
11.4.2 Retinotomy and Retinectomy 242
11.4.3 Radial Retinotomy 245
11.4.4 Scleral Encircling and Buckling 245
11.5 Summary 246
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Contents
xxv
12 Vitreoretinal Surgery in Children and Adolescents 247
12.1 General Characteristics and Unique Challenges 247
12.2 Surgical Management of ROP 250
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12.2.1 Overview of the Third Edition of ROP Classication 250
12.2.2 Anti-VEGF Intraocular Injection 253
12.2.3 Retinal Laser Photocoagulation 255
12.2.4 Vitreoretinal Surgery 256
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12.3 Rhegmatogenous Retinal Detachment Secondary to FEVR 258
12.3.1 Overview 258
12.3.2 Clinical Staging of FEVR 259
12.3.3 FEVR and RRD 259
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12.3.4 Principles of Surgical Management 260
12.4 Retinal Detachment Secondary to Stickler Syndrome 261
12.4.1 Typology of Stickler Syndrome 262
12.4.2 Clinical Features of Stickler Syndrome 262
12.5 Summary 264
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13 Editing and Presentation of Surgical Videos 265
13.1 Unique Characteristics of Vitreoretinal Surgical Videos 265
13.2 Core Elements of Surgical Videos 266
13.3 Basic Parameters of Surgical Videos 267
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13.4 How to Adjust Your Camera and Microscope 269
13.5 Choosing the Right Editing Software for Efciency and Quality 270
13.6 Fundamental Steps and Matters Needing Attention 272
13.7 Protection of Patient Privacy and Intellectual Property 278
13.8 Showcase Your Art Works 278
13.9 Summary 279
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Part III Vitrectomy in Europe
14 General Introduction to Vitreoretinal Surgery in Europe 283
14.1 Education of Vitreoretinal (VR) Surgery 283
14.2 Easy and Difcult Vitrectomy 283
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14.3 Cataract Surgery and Vitrectomy 284
15 Combined Phaco/Vitrectomy 287
15.1 The Surgery 288
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15.2 Main Surgical Steps 289
15.3 The Surgery Step-by-Step 289
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15.3.1 25G/27G Three-Port System with Chandelier Light 289
15.3.2 Phacoemulsication 289
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15.3.3 Core Vitrectomy and Posterior Vitreous Detachment 292
15.3.4 Mark the Breaks with Endodiathermy 292
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15.3.5 Injection of PFCL to Posterior Edge of Break
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15.3.6 Vitrectomy of the Tear Flap and the Peripheral Vitreous 293
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xxvi
Contents
15.3.7 PFCL Injection Up to Ora Serrata 294
15.3.8 Laser Therapy of Breaks 295
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15.3.9 Trimming of Vitreous Base (Shaving) 296
15.3.10 Fluid Against Air Exchange 298
15.3.11 Drainage of Subretinal Fluid 298
15.3.12 Complete Laser Coagulation 301
15.3.13 Tamponade 301
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15.3.14 Removal of the Trocar Cannulas 303
15.3.15 FAQ 307
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16 Encircling Band, Vitrectomy, Retinotomy, and C3F8
(Stockholm Technique) 309
16.1 Surgery 311
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16.2 Main Surgical Steps 311
16.3 Every Step in Detail 311
16.4 FAQ 313
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17 Easy Diabetic Retinopathy 315
17.1 Introduction 315
17.2 Combined Phacoemulsication and Anti-VEGF Treatment 316
17.3 Vitrectomy 318
17.3.1 The Surgery Step-by-Step 319
17.3.2 Complications 321
17.4 FAQ 321
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Part IV Difcult Vitrectomy in Europe
18 Usage of a Chandelier Light 325
18.1 Insertion of Chandelier Light 326
19 Vitrectomy for Difficult Retinal Detachment (PVR) 329
19.1 Introduction 329
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19.2 Instruments for PVR Detachment 330
19.3 The Surgery Step-by-Step 330
19.4 Every Surgical Step in Detail 331
19.4.1 Encircling Band (cerclage) 331
19.4.2 Phacoemulsication and IOL Implantation 331
19.4.3 Pars Plana Vitrectomy 331
19.4.4 Vitreous Staining with Triamcinolone 333
19.4.5 Vitreous Base Shaving 333
19.4.6 Membrane Dissection 333
19.4.7 Removal of Epiretinal Membranes 334
19.4.8 Removal of Subretinal Proliferations 337
19.4.9 Retinotomy 337
19.4.10 Instillation of PFCL 338
19.4.11 Laser Photocoagulation 339
19.4.12 Prepare the Anterior Chamber 340
19.4.13 Tamponade 340
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Contents
xxvii
20 Difficult Proliferative Diabetic Retinopathy 347
20.1 Introduction 347
20.2 General Introduction 349
20.3 The Surgery Step-by-Step 351
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20.3.1 Three-Port Trocar System with Chandelier Illumination 351
20.3.2 Posterior Hyaloid Rhexis 351
20.3.3 Removal of Tractional Membranes 354
20.3.4 Instruments for the Removal of Proliferations 354
20.3.5 Hemostasis 359
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20.3.6 Removal of Attached Posterior Hyaloid in the Periphery 362
20.3.7 Panretinal Photocoagulation (PRP) Under BSS 364
20.3.8 Fluid Against Air Exchange 364
20.3.9 Intravitreal Avastin 365
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20.3.10 Internal Postoperative Tamponade 365
20.3.11 Removal of Trocars 367
20.4 Complications 368
20.5 FAQ 368
Bibliography 371
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Abbreviations
AC Anterior Chamber
AGEs Advanced Glycation End Products
AL Axial Length
AMD Age-related Macular Degeneration
BBG Brilliant Blue G
BIOM Binocular Indirect Ophthalmomicroscope
BSS Balanced Saline Solution
C2F6 Peruoroethane
C3F8 Peruoropropane
CME Cystoid Macular Edema
cpm Cuts Per Minute
CSF Colony-Stimulating Factor
D Diopter
DOF Depth of Field
ECG Electrocardiogram
ECM Extracellular Matrix
EGF Epidermal Growth Factor
EMT Epithelial–Mesenchymal Transition
ERM Epiretinal Membrane
FA Fluorescein Angiography
FDA Food and Drug Administration
FEVR Familial Exudative Vitreoretinopathy
fps Frames Per Second
G Gauge
GRT Giant Retinal Tear
H.264/AVC Advanced Video Coding
H.265/HEVC High Efciency Video Coding
ICG Indocyanine Green
ICROP International Classication of Retinopathy of Prematurity
IGF Insulin-like Growth Factor
ILM Internal Limiting Membrane
IMH Idiopathic Macular Hole
IOP Intraocular Pressure
IOL Intraocular Lens
xxix
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kbps Kilobits per Second
KPs Keratic Precipitates
LIO Laser Indirect Ophthalmoscopy
MCP-1 Monocyte Chemoattractant Protein-1
MH Macular Hole
MH-RD Macular Hole Retinal Detachment
N2 O Nitrous Oxide
NCT Non-contact Tonometry
NRD Non-rhegmatogenous Retinal Detachment
OCT Optical Coherence Tomography
PAT Preferences and Trends Survey (ASRS)
PCO Posterior Capsule Opacication
PCV Polypoidal Choroidal Vasculopathy
PD Optic Disc Diameter
PDGF Platelet-Derived Growth Factor
PDR Proliferative Diabetic Retinopathy
PFCL Peruorocarbon Liquid
PFD Peruorodecalin
PFO Peruoro-octane
PFOB Peruorooctyl Bromide
PFTB Peruorotributylamine
PDMS Polydimethylsiloxane
PPV Pars Plana Vitrectomy
PRP Panretinal Photocoagulation
PVD Posterior Vitreous Detachment
PVR Proliferative Vitreoretinopathy
RD Retinal Detachment
ROP Retinopathy of Prematurity
RPE Retinal Pigment Epithelium
RRD Rhegmatogenous Retinal Detachment
SF6 Sulfur Hexauoride
TA Triamcinolone Acetonide
TB Trypan Blue
TGF-β Transforming Growth Factor-Beta
TRD Tractional Retinal Detachment
UBM Ultrasound Biomicroscopy
VA Visual Acuity
VEGF Vascular Endothelial Growth Factor
VH Vitreous Hemorrhage
VMT Vitreomacular Traction
VR Vitreoretinal
Abbreviations
Part I
Basics of Vitreoretinal Surgery
A Brief History oftheDevelopment
ofVitreoretinal Surgery
The history of vitreoretinal surgery is marked by exceptional pioneers who combined surgical talent with rigorous scientic inquiry. Leveraging rapid technological
progress, they tirelessly rened their craft and expanded the horizons of what was
insurmountable obstacles of the fundus. Through their persistence, the dream of
‘seeing’ has become a clinical reality. We now revisit these individuals and events
with profound reverence.
1.1 The Evolution ofTreatment Eras forRhegmatogenous
Retinal Detachment
1
thought possible. Their legacy has enabled today’s surgeons to overcome the once-
1.1.1 Pre-Jules Gonin Era
Beginning in 1805, scholars such as Ware, Wardrop, and Panizza published reports
on retinal detachment, a sight-threatening disease. However, because the ophthalmoscope had not yet been invented, diagnosis could only be inferred from clinical
symptoms. Not until the mid-nineteenth century, following the invention of the
direct ophthalmoscope, did the diagnosis of retinal detachment become intuitive
and reliable (Fig.1.1). Even so, treatment of the disease remained in its infancy.
In 1805, Ware made the rst attempt to treat retinal detachment by puncturing the
sclera with a scalpel to drain subretinal uid. Then, in 1863, Albrecht von Graefe
(1828–1870) of Germany modied this approach: he intentionally created retinal
breaks to allow subretinal uid to escape into the vitreous cavity.
Von Graefe lost both parents by the age of 12. His father had been a renowned
professor of ophthalmology at the University of Berlin. As an adult, von Graefe
resolved to follow in his father’s footsteps. He not only possessed superb medical
skills but also insisted on providing free medical services to low-income patients. In
1854 and 1857, he founded, respectively, the ophthalmology journal Albrecht von
Graefes Archiv für Ophthalmologie (now known as Graefe’s Archive for Clinical
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2026
Z. Zhang, U. Spandau, Vitreoretinal Surgery,
https://doi.org/10.1007/978-3-032-25271-5_1
3
4
1 A Brief History oftheDevelopment ofVitreoretinal Surgery
Fig. 1.1 Direct ophthalmoscope without a built-in light source commonly used in the early twentieth century. (Photo courtesy of the American Society of Retina Specialists History of Retina)
and Experimental Ophthalmology) and the German Ophthalmological Society. For
his numerous foundational contributions to ophthalmology in the nineteenth century, he is remembered as the “father of modern ophthalmology.”
In 1883, Grossman pioneered the subconjunctival injection of hypertonic saline
to create an osmotic and hydrostatic gradient across the sclera, thereby promoting
transscleral drainage of subretinal uid. Other historical approaches sought to
increase intraocular pressure as a treatment for retinal detachment. For instance, in
1925, Carbone advocated injecting vitreousand gelatin into the anterior chamber.
Some surgeonsinjected rabbit vitreous, protein solutions, or ltered air into the
vitreous cavity to raise intraocular pressure and reattach the retina. Still others went
so far as to attempt suturing the retina to the ocular wall.
Despite these numerous efforts, the success rate of retinal detachment surgeryremained
extremely low. Thecommunity, once highly enthusiastic, gradually sank into despair. In
1904, retinal detachment was even declared an incurable disease at an international conference in Paris. This was by no means a rash conclusion: data from 1912 indicated that
the reported success rate of retinal detachmentamong ophthalmologists in the United
States was a mere 0.1%—a gure that cast the eld into deep despair.
1.1 The Evolution ofTreatment Eras forRhegmatogenous Retinal Detachment
5
1.1.2 Post-Jules Gonin Era
making ophthalmologist was Jules Gonin. Born into a culturally devoted family in
Lausanne, Switzerland, Gonin displayed exceptional linguistic talent from an early
age, mastering French, German, Latin, Greek, English, and Spanish. At 18, he
entered the University of Lausanne to study medicine, and in 1896, he launched his
distinguished career as an ophthalmologist.
Gonin’s major contribution was his proposal that retinal breaks are the primary
cause of retinal detachment, and therefore the key to successful surgery lies in sealing these breaks. In 1919, he designed a set of surgical instruments (Fig.1.2) and
began treating retinal detachment by cauterizing the sclera beneath the identied
breaks, achieving increasingly satisfactory outcomes. Precise localization of all retinal breaks prior to surgery remains a core step of this technique.
Like most new theories and methods, Gonin’s ideas and surgical techniques were
not widely accepted by his peers at rst. The community remained committed to the
mainstream approach of directly draining subretinal uid surgically. Nevertheless,
Gonin held rm to his judgment and continued to carry out effective clinical practices. It was not until the International Congress of Ophthalmology in Amsterdam
The emergence of a gifted gure completely reversed this situation. That epoch-
Fig. 1.2 Surgical instruments for retinal detachment designed by Jules Gonin. (Photo courtesy of
the American Society of Retina Specialists History of Retina)