(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
The list of conditions amenable for VR surgery is long and growing. Each condition has its own arguments in favor of and against surgery, which need to be discussed with the patient so that he, together with the surgeon, can come to a decision (see Chap. 5). In this chapter only a few basic thoughts regarding indications are discussed, strictly from a medical standpoint.1
8.1 The Argument in Favor of Surgery
Why surgery should be done is rather obvious: it promises the chance of visual improvement, the prevention of its worsening, or, as a minimum, the preservation of the globe.
Q&A
Q
Can the surgeon promise functional success?
A
Never. With certain indications such as floaters, the chances of improvement are excellent, but still not 100%. All the surgeon can promise is to try his very best to help. Surgeons cannot restore function; they restore anatomy, with a reasonable hope that function will follow. It is also not possible to predict how much improvement will occur. Statistically, one can give a general prognostic figure, but the surgeon must always emphasize that the statistical average or range is not necessarily true for that particular person or operation.
Every time a medical intervention, whether surgical or not, is considered, one of the key questions is the risk-benefit ratio. No intervention should be performed, even at the specific request of the patient, if the former is greater than the latter (see Table 5.1).
Usually it is relatively easy to determine whether the chance of improving (preserving) function is indeed higher than the risk of deterioration due to a complication (or natural history).
The benefits a successful surgery brings3 are obvious: an attached retina’s function should improve, a vitreous is no longer opaque, the macula is smooth again etc.
Often the patient “sees the difference” the next day; in other cases he is warned that his vision may be even worse than preoperatively but that this is temporary (e.g., gas tamponade, see Sect. 35.2.2).
More difficult to appreciate is an operation that does not improve function, “only” preserves the current status; such an indication requires even more extensive counseling than usual.
Pearl
A somewhat similar question is whether to perform a certain surgical maneuver (e.g., laser around a posterior retinotomy, see Sect. 30.3.1) if it is done not because it has proved to be necessary but because the surgeon will “sleep better if he did it.” This argument is not totally wrong: as long as the maneuver has a rationale (at least some scientific merit) and its risk is low, the surgeon can claim, should the disease course turn for the worse, that he tried everything (instead of having to say: “If only I had done that maneuver in the first place…”).
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