Retinal patients often have glaucoma, often mismanaged or unrecognized by their primary ophthalmologist or optometrist, as unbelievable as this might seem. Ocular surface disorders are incredibly common and affect vision, not just comfort, as well OCT imaging quality.
Many vitreoretinal surgeons have missed a lymphoma by performing a misdirected uveitis workup seeking vaguely connected autoimmune disorders. A central retinal artery occlusion or branch retinal artery occlusion needs carotid and aortic valve ultrasonic imaging to detect atherosclerotic plaque, however minor, and consideration of anti-coagulation by an internist.
It is unacceptable to miss an aneurysm, choroidal metastases or papilledema; you must think about the patient not just the eye or retina. Communicate with a neurosurgeon, cardiologist or oncologist directly. To avoid delays and prevent crucial medical problems being overlooked, resist the habit of just ordering tests and instead, “order doctors.”
Visualization is essential in vitreoretinal surgery but not an argument to do a phaco-vit in a majority of cases.
Today’s patients expect near-perfect refractive outcomes. Don’t dabble in cataract surgery; if you cannot see well enough to perform high-quality vitreous surgery, send the patient for cataract surgery before performing macular surgery. Phaco-vit surgery does not produce consistent, precise refractive outcomes that patients want and deserve.
Vitrectomy does not cause cataract; it causes rapid progression of pre-existing nuclear sclerosis. Do not hesitate to do a lensectomy in inflammatory, proliferative vitreoretinopathy, complex trauma or uveitis cases. Do not leave capsule, touch iris or implant an intraocular lens in severe uveitis vitrectomy cases. Contact-based macular visualization produces better lateral and axial resolution (modulation transfer function) than non-contact visualization (BIOM, Oculus, or ReSight, Carl Zeiss) by eliminating all corneal asphericity. Contact-based wide angle-visualization provides 10 degrees greater field of view than non-contact and better resolution.
Vitreoretinal surgery is not an extreme sport or fame game.
Surgery is not about making a show-and-tell video or doing combined procedures, endoscopy or intraoperative optical coherence tomography; it is about focusing on the primary surgical goal—restoring or preserving vision. Overly aggressive posterior vitreous detachment creation causes many iatrogenic retinal breaks and excessive use of silicone oil.
Linear thinking produces bad outcomes; multi-branching algorithms are essential for problem solving.
Understanding, concept-based learning is essential and is far more effective and utilizable than rote memorization, content-based learning. Vitreoretinal surgeons should understand the physics behind surgical fluidics and imaging, the physical chemistry of silicone oil, gas and liquid perfluorocarbon, and the biology of angiogenesis and apoptosis. The surgeon must learn how to set up and operate all vitreoretinal machines to avoid mistakes and dependence on the OR staff.
There is no standard approach or “gold standard” in medicine.
Technology, techniques and bio-science rapidly evolve and the surgeon must evolve in parallel. Vit-buckles are obsolete; they produce poor refractive outcomes, pain and strabismus; are not cost effective because of long operating times; and definitely not minimally invasive.
Lifetime learning is essential to the practice of medicine.
| Surgery is not about making a show-and-tell video ... it is about restoring vision. |
Surgical goals and techniques are diagnosis-dependent.
The highest possible cutting rates should be used for all tasks and all cases except for dense fibrous tissue after the vitreous has been removed. Virtually all macular surgery patients require brilliant blue assisted internal limiting membrane peeling using ILM forceps peeling; the indications include epimacular membrane, partial and full thickness macular holes, vitreomacular schisis and vitreomacular traction syndrome.
Indocyanine green can be toxic and should be replaced by brilliant blue for ILM staining; triamcinolone particulate marking is not specific for ILM. Peripheral vitreous shaving is not indicated for macular surgery patients but retinal detachment patients with or without PVR require removal of the majority of peripheral vitreoretinal traction.
Scissors delamination skills are essential for diabetic traction retinal detachment surgery even though 25/27 ga. conformal and foldback cutter delamination using high cutting rates allows the surgeon to safely remove substantial epiretinal membrane. Endophotocoagulation is preferable to laser indirect ophthalmoscope for retinopexy and panretinal photocoagulation in a vitrectomy setting. Endophotocoagulation is better than diathermy for hemostasis because it reduces collateral damage and is non-contact. Reoperation for PVR or epimacular membrane in patients with silicone oil should be performed “under” oil, not by removing oil and reinjecting it. Operation under oil is a subset of interface vitrectomy; vitrectomy under PFO and vitrectomy under air are crucial parts of the surgeon’s technique repertoire. Medium-term perfluoro-n-octane (two weeks) is ideal for all inferior retinal detachments including phakic eyes, PVR, primary rhegmatogenous retinal detachments, inferior, nasal and temporal giant breaks.
Play by the rules of coding and billing but do not obsess over finances.
Income will come if the focus is on hard work and high quality, ethical, compassionate patient care. REVIEW
Dr. Charles is a clinical professor of ophthalmology at the University of Tennessee Hamilton Eye Institute. Contact him at: Charles Retina Institue, 6401 Poplar Ave., Ste 190, Memphis, Tenn. 38119. scharles@att.net.
