(1)
St. Johns, FL, USA
(2)
Helen Keller Foundation for Research and Education, International Society of Ocular Trauma, Birmingham, AL, USA
(3)
Consultant and Vitreoretinal Surgeon, Milos Eye Hospital, Belgrade, Serbia
(4)
Consultant and Vitreoretinal Surgeon, Zagórskiego Eye Hospital, Cracow, Poland
3.1 Plan (Not Trial and Error)1
No VR surgeon should operate on a patient without first designing a plan, which is to be based on the characteristics of the condition in general and the characteristics of the condition in that specific person’s eye in particular.2 The plan involves three levels, the first two of which are strategic and the third tactical (see Table 3.1).
Table 3.1
The three levels of planning in VR surgery
Level | Comment |
|---|---|
One: The strategy of the entire treatment process from the end of the evaluation to the final follow-up visit. Prevention of possible complications is incorporated in the plan | This is the most fundamental part of the plan: What number of surgeries appears to be ideal to allow reaching the most optimal final outcome?a It may be preferable to forego a comprehensive (all-in-one) reconstruction and instead choose a staged approach with multiple surgeries. In the latter case (for instance, for an eye with a severe rupture that caused lens extrusion, vitreous hemorrhage, major retinal damage, and iris retraction), the surgeon must also develop a plan regarding the timing of each intervention. If a single surgery is sufficient to deal with the pathology,b planning on level one and level two merges into a single strategy, which includes the preoperative, perioperative, and postoperative medical treatment as well as the operation itself plus its timing |
Two: The strategy concerning the upcoming operation. Prevention of possible complications is incorporated in the plan | The surgeon should know what he intends to achieve during that particular surgery (see the text for more details). To close a macular hole, for instance, the main surgical stepsc include vitreous removal (with a preoperative decision regarding the amount of vitreous to be removed; see Sect. 27.2), ILM peeling, and gas tamponade |
Three: This is the tactical level. Prevention of intraoperative complications is incorporated in the plan | The VR surgeon must make severald intraoperative decisions related to the actual surgical technique (tissue tactics). Should a proliferative membrane, for instance, be bluntly dissected or sharply cut, and if the latter, whether with the probe or scissors, and if the latter, which type of scissors? Exactly where should the membrane be cut? At what angle should the scissors be held when the handle is finally squeezed? |
One to three: No part of the plan must be in stone | As the treatment progresses, whether it relates to strategy such as staging and timing or tissue tactics such as the technique of ILM peeling, the surgeon must carefully observe how the tissue, the eyeball, and the person react to his actions (feedback on multiple levels). If the outcome of his activity differs from the expected,e he must modify the plan accordingly, on any or all three levels. If for instance the original plan called for two surgeries but during the first operation the surgeon realizes that all his original long-term goals can be accomplished in this sitting, the second surgery becomes superfluous |
No VR surgeon should begin the treatment process without knowing three basic things:
The condition of the eye at the onset – point A.3
The expected condition of the eye at the termination of the intervention (the ideal, hoped-for outcome) – point B.
How to get from point A to point B.
To sit down to the operating table and address each tissue pathology as it comes into view and deal with the technical challenges only as they emerge without first designing a plan is ineffective in its process and suboptimal in its outcome. Amazingly, the very surgeon who practices such a re-active type of surgery4 would never himself consider driving in an unfamiliar city from his current location (point A) to his destination (point B) without first consulting a map or GPS device to plan the route.
Pearl
Just as a driver who encounters a roadblock or traffic sign that forces him to alter his planned route, a surgeon who finds an unexpected pathology or tissue behavior must change his original plan according to what the new findings dictate.
As in the driving example, the surgical plan cannot be formulated without the surgeon having a clear idea about the desired anatomical outcome of that particular operation. Instead of making ad hoc decisions as pathologies emerge, the surgeon’s tactical decisions are in harmony with the strategy.5 This long–term thinking has multiple advantages (see Table 3.2).
Table 3.2
Long-term vs short-term planning for a patient requiring VR surgery
A 48-year-old male presents with a 6-day history of vision loss; he has 3 D of myopia. He has a macula-off RD with a large tear at the equator inferotemporally. The vitreous is full of pigmented cells, and the tear’s edge is curled | |||
|---|---|---|---|
Treatment selection | Plan A, focusing on the short term | Plan B, focusing on the short term | Plan C, focusing on the long term |
Rationale for choosing that particular option | Without surgery, the eye will go blind There is a risk of PVR, but both the RD itself and the risk of PVR can be taken care of by traditional SB surgery. The break has to be lasered. Gas tamponade is needed to temporarily cover the break | Without surgery, the eye will go blind There is a risk of PVR; while the RD could be taken care of by traditional SB surgery, the PVR risk requires vitreous removal. The break is inferior; therefore adding a SB increases the chance of success. The break has to be lasered. Gas tamponade is needed to temporarily cover the break | Without surgery, the eye will go blind.The PVR risk is high, surgery therefore must be complete PPV to relieve the current traction and address the one on the horizon: PVR. For the latter, silicone oil is needed. The laser must surround the break but also be circumferential (cerclage) to provide additional support. The lens will become cataractous and is better removed now |
Actual treatment plan | A radial SB after external drainage of the subretinal fluid and laser around the break to seal it. An additional encircling band against any future traction and 0.5 ml of pure SF 6 for tamponade | Vitrectomy, SB (segmental or circumferential), laser, and 30% SF 6 tamponade | Cataract extraction with IOL implantation, capsulectomy, total vitrectomy, endolaser cerclage, silicone oil implantation |
It requires careful consideration whether an eye that is likely to develop PVR requires primary in-the-bag IOL implantation.
The surgeon should try to anticipate complications such as PVR, which may arise due to the condition itself or as a result of his own intervention. He must try to reduce the risk (prophylactic chorioretinectomy; see Sect. 33.3).
Pearl
A good surgeon is akin to a defensive driver who not only drives carefully but is constantly on alert: keeping watch over all the other drivers around him and trying to anticipate what those drivers may do. A surgeon must never be on autopilot and never do maneuvers as a matter of reflex or custom – there must be a reason for everything he does (or does not do).
A pseudophakic eye requires a capsulectomy.
With the probe it is possible to create a capsulectomy regardless of the thickness of the capsule and without the risk of damaging the IOL; in addition, the capsulectomy is precisely of the desired size.
Performing capsulectomy assures instant and permanently excellent visibility for both patient and ophthalmologist.
True, YAG laser will probably also allow opening the posterior capsule at any time postoperatively, but the opacified capsule will interfere with visualization until then. The laser also produces a large, permanent floater that may be bothersome to the patient, a consequence that could easily have been avoided by planning ahead.
Leaving the posterior capsule intact has one, intraoperative, advantage: no risk of IOL fogging during F-A-X (see Sect. 25.2.3.4).
Finally, it must be emphasized that as technology evolves, surgical techniques improve, new materials become available etc., the surgeon must also change. The same condition that a few years ago would have required a certain plan to treat may require a very different plan today.8
Figure 3.1. is an illustrative example of planning. It is from “civilian life,” outside ophthalmology, but it shows the mindset that the VR should develop to replace “instinct” with thinking ahead.
