(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
Ophthalmology residents who decide to become a VR surgeon have at least some experience in performing anterior segment surgery, mainly cataract extraction. Such a background provides a good basis for specializing in posterior segment work – but no more than a foundation for it.
Training for VR surgery is a long, indeed never-ending, process. If the ophthalmologist is fortunate enough to live in one of the few countries in which formal schooling (fellowship) is available, his path to becoming a trained VR surgeon is charted. Most residents, however, will not have access to such tried-and-tested programs and must design their training program themselves. This chapter provides guidelines for such an endeavor.1
Pearl
For someone aspiring to become a VR surgeon, the importance of proper training cannot be overemphasized. Without such training many operations will end in failure for the surgeon and visual loss for the patient. Repeating the same erroneous intravitreal maneuvers will predictably result in the same tragic outcome. Facing failure after failure, these surgeons will eventually give up VR surgery, at the cost of blind patients and the loss of self-confidence.
2.1 The “To-Do” List2
The fellow should do all of the following:
Select an experienced and willing VR surgeon3 at the fellow’s institution, who will serve as a mentor for the entire training period (see the Appendix, Part 1).
Read the most important books and articles on VR surgery – the mentor should help with the selection process.
Attend meetings where peers, preferably from the international community, discuss the latest development in the VR field.4
Spend the maximum possible time with the mentor,5 examining patients in the outpatient department. Many a pathology will be seen and you should understand how the decision whether the condition in that particular patient is amenable for surgery is made.6
Follow the patient after PPV, preferably long term. This helps recognizing complications and their treatment, and also, in retrospect, to see whether the decision to go to surgery was correct.
Assist in surgery as often as possible.7 Assisting, again, must never be spent by passively staring at the microscope or monitor (see Table 2.1). As always, the more experience gained, the easier and more useful such observing/assisting becomes.8
Table 2.1
The rules of assisting/observing in VR surgerya
Element
Comment
Talk to the surgeon before the operation
Explain to him that you came to learn and that you are very interested in what he is going to do; ask him if he is comfortable with you asking lots of questionsb
The condition of the eye
Note the anatomical relationships; formulate a strategic goal (what the eye’s condition at the end of the operation should be) and then the tactical goals (the tissue manipulations needed to achieve that final anatomical condition). Of these two basic categories, initially the second is more obvious; as the experience grows, the strategic issues will gain importancec
The surgeon’s next move
Try to expect what this move will be (what you would do in this situation). There are two possibilities, detailed next
Move is what you expected
Be proud of yourself
Move is not what you expected
This is the moment of truth: if you are able to figure out why his move was not what you expected, you learned something
If you cannot determine why the surgeon acted differently from your expectation, you must ask him why he did what he did d
Asking the surgeon “why”
Most surgeons will not be willing to answer you during the operation. You must make a mental note (if you are assisting) or a quick written one (if you are observing) about the exact situation and how the surgeon’s action diverged from your expectation, and ask him after the operation
A few surgeons are willing to answer the question right there and then. These are the surgeons you will benefit from the most since you can instantly learn something
A few surgeons actually encourage you to comment, not simply answer your questions; this is the absolute best option since it makes your newly gained experience a truly active one. These are the surgeons you should often revisit
Conversely, some surgeons will not answer you at all or give you an obviously bogus answer. Leave him
It is highly advisable to learn from more than a single surgeon, however good he is. Different surgeons have different approaches to the same problem, and, optimally, the fellow is exposed to a variety of options. Even when the fellow sees something “horrifying,” it is helpful: he now definitely knows that he will never do this in his own practice.
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