Ferenc Kuhn

Materials and Their Use

From fluid to various types of short- or long-term tamponades, as well as different “third-hand” tools employed intraoperatively, the VR surgeon uses many materials that can increase the chance of success when used correctly – or lead to complications when wrongly selected or inappropriately applied. Sutures also require a discussion about their characteristics and usage, which is especially important today when suturing is less commonly needed in routine surgery and therefore even its very basics are neglected in resident training programs

Holding and Operating Hand Instruments

With good reason, no chair has only two legs; by the same logic, instruments should not be held with two fingers only. The VR surgeon must understand, if not intuitively then by learning, how to hold an intraocular instrument securely and efficiently. The actual operation of the tool, such as the grabbing of a membrane with a forceps, is best broken down into the particular elements of the movement to optimize the maneuver; finally, the surgeon must learn to overcome the unintentional reflex of continually squeezing the instruments, even when they are not actually operated.

The Indication Whether to Operate

Why to operate is usually very easy to justify: because there is blood in the vitreous cavity, a scar tissue over the macula, etc. Why not to operate is typically not obvious until serious intra- or postoperative complications occur, which will have lead to a worse anatomic and functional outcome than those of the natural history. The decision in favor of the operation is thus not always a straightforward one, especially because no surgeon can, or should, promise success; furthermore, even if the anatomy is successfully restored, consequent functional improvement is not inevitable.

The Basics of Vitreous Removal

Vitreous is not removed “just because it’s there,” even though it has many beneficial effects. The rationale for performing vitrectomy (“why”) is just as important as its techniques (“what,” “how”), and this is true in each case. Even if this would appear obvious, the amount of gel to be removed is not self-evident, and this is especially true regarding PVD and the anterior vitreous. It is not always easy to determine how much vitreous is (still) present; visual aids are thus not only useful but also necessary to avoid leaving vitreous behind. “Not enough vitrectomy” is a common cause of postoperative complications – as opposed to “too much vitrectomy,” which in itself is never a source of complications. The sequence of gel removal (where to start? how to proceed?) is another area of contention.

How to Train as a VR Surgeon Outside a Formal Fellowship

VR surgery is a complex procedure, requiring special training to optimize the surgeon’s decision-making process (“the brain”) and achieve the required dexterity (“the hands”). If the fellow has no possibility to be in a formal training program, he must identify experienced and accomplished VR surgeons at other institutions – often in other countries – who are willing to take them on as “unofficial” fellows. These visits are typically rather short but extremely useful as long as the mentors (tutors) honestly share their experience and the fellow is able to process all the new information and consciously build on it. Repeated visits, including to different mentors, even after the fellow has started his own career, are indispensable mileposts on the road to becoming a well-trained surgeon.

Vitrectomy Performed via the “Standard” Method and Its Alternatives

Traditionally and in the vast majority of the cases, three pars plana sclerotomies are prepared, and the surgery is viewed through the microscope and the BIOM (or a macular contact lens), but using the slit lamp or the endoscope is a viable option, with their own advantages and drawbacks. Another option is the use of a portable system and the viewing of the operation through the IBO.

Major Equipment, Their Accessories and Use

This chapter reviews the general attributes and the criteria for the personalized setup of the major equipment and their individual components. The discussion includes the vitrectomy machine itself, ranging from the pump and the characteristics of the probe (duty cycle, cut rate, etc.) to the interface display, as well as all elements of the viewing system: the microscope and the BIOM.

Handling of Major Intraoperative Complications

There is only one scenario in ophthalmology when literally seconds count before irreversible loss of vision occurs: an expulsive type, arterial hemorrhage. Even if this is less common in vitrectomy than in an open-globe type of surgery, the risk is not negligible, and every (VR) surgeon must know how to recognize and manage it. More frequent is the occurrence of a retinal tear, which, if unrealized and untreated, can rapidly lead to RD. Iatrogenic trauma to the lens is another complication that less experienced surgeons occasionally cause.

Macular Disorders Related to Traction: VMTS, Cellophane Maculopathy, EMP, Macular Hole

There are several different pathologies that can damage vision by exerting traction on the macula. The patients with such conditions are often more bothered by metamorphopsia than by the drop in visual acuity. The surgical intervention is somewhat similar in these conditions with a few special characteristics for each indication, and the VR surgeon must be aware of these to avoid certain complications while maximizing the success rate. Even though most macular holes will be closed with today’s advanced techniques, a few will not; the best method of reoperation is controversial.

The Surgeon at the Operating Table

There are many issues to consider before the surgeon finally sits down to “do the case,” including the following: familiarity with the team he will be working with; ensuring that he can maintain the most ideal and comfortable posture during the next surgery and throughout the day by adjusting to his preferences the operating table, his own chair, and the microscope; having all the pedals properly positioned; setting up the BIOM appropriately; programming the vitrectomy machine properly; selecting a relatively low brightness level for the microscope and room lights so that neither is blinding when turned on after a period of darkness; setting a temperature in the OR that is within his comfort zone; having all the necessary equipment readily available and accessible; and making everybody on the VR team understand that while he would listen to their advice, the surgeon remains the “captain in the OR.”