Abstract
No VR surgeon should ever perform an operation without planning it on both the strategic (such as staging or timing) and tactical (tissue manipulations) level. For such planning the surgeon must be aware of where he is now (the preoperative condition of the eye), where he wants to be at the completion of the treatment (the condition of the eye at the end of the current operation but also of the entire treatment process), how to get there (the roadmap of the current surgery and the number of planned surgeries), and what needs to be avoided or prevented (intra- and postoperative complications).
During surgery the surgeon must have control over all events, not leave anything up to chance; he must therefore know the rationale for everything he does and not be influenced by dogmatic rules or peer pressure.
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- 1.
Behavioral economics provide an excellent example of the difference between reflective (autopilot-like) action vs one based on conscious consideration. Answer the following question: if the ball and the racquet together cost $11 and the racquet costs $10 more than the ball, how much does each cost? The reflective, rapidly given answer is $10 and $1; the considerate one says $10.50 and <Footnote ID=”Fn2”><Para ID=”Par5”>Behavioral economics provide an excellent example of the difference between reflective (autopilot-like) action vs one based on conscious consideration. Answer the following question: if the ball and the racquet together cost $11 and the racquet costs $10 more than the ball, how much does each cost? The reflective, rapidly given answer is $10 and $1; the considerate one says $10.50 and $0.50.</Para></Footnote>.50.
- 2.
This may be a very accurate diagnosis such as a visible macular hole or, less commonly, a vague one such as in an eye with a massive VH.
- 3.
“Let’s go step by step and see what happens.”
- 4.
Another analogy to describe the difference between the two approaches is the example of two football coaches who have the purse to buy new players. One coach buys famous players with the hope that their talent will naturally give birth to a team system; the other one buys players who he thinks will fit his existing coaching philosophy. The second coach should have a higher chance of creating a winning team.
- 5.
The implantation is performed months after the silicone oil has been removed.
- 6.
Another example of long-term thinking is a patient with PDR: the VA is full but the tractional detachment is progressively approaching the fovea. A surgeon with short-term thinking simply hopes that the TRD never progresses that far and defers surgery until the fovea does detach. A surgeon with long-term thinking explains to the patient what is likely to unfold, but also the risks of the surgery, and, with the patient’s informed consent, operates before the fovea detaches.
- 7.
One illustrative example: In severely injured eyes I used to preserve the anterior capsule and implant, as the very last step of the treatment process, a sulcus-fixated IOL. In recent years I switched to removing both capsules and implanting an iris-claw IOL (usually possible even if the iris had also been injured and required suturing; see Sect. 38.6).
- 8.
Level three, tissue tactics.
- 9.
“Because I always do it this way”; “because that’s what I was taught”; “what do you mean?”
- 10.
Why did you use a bent needle and not a forceps to lift that membrane? Why did you cut the subretinal strand rather than take it out? Why did you just change the direction of peeling the ILM? The fellow must behave in the OR as a young child who is constantly “pestering” his parents with “why?” questions.
- 11.
If I cannot answer a visitor’s “why?”question, it forces me to reconsider the issue in question to either find the rationale for it or look for a more effective option.
- 12.
Another evidence in favor of planning all aspects of surgery well in advance.
- 13.
I recently heard a presentation by a well-known retina specialist about a patient with diabetic macular edema. He received 36 monthly intraocular injections (at ~$2,000 each); the plan was to continue the treatment. Common sense tells you that if a therapy is expensive and does not work, you do not “blindly” follow a study’s blanket recommendation but switch therapy.
- 14.
This principle extends to include studies that are “evidence-based.” Just because such proof of the efficacy of a certain treatment option once existed, it does not necessarily mean that years after the publication of that study it still holds water.
- 15.
The British Medical Journal published a sarcastic article in December 2003 about the “effectiveness of [the] parachutes,” stating that this “has not been subjected to rigorous evaluation by using randomized controlled trials… everyone might benefit if the most radical protagonists of evidence-based medicine organized and participated in a double-blind, randomized, placebo-controlled, crossover trial of the parachute.”
- 16.
In other words, Mr. A. will do fine with therapy X, but Mr. B. is better off with therapy Y.
- 17.
The football (soccer) coach’s cliché warning to his players is that the game lasts 90 min; whether the other team wins by scoring in the first or last minute does not matter, you still lose.
- 18.
Such as panretinal endolaser treatment, which requires very little “brain work.” A surgeon who delivers over 2,000 spots is at risk of losing focus and venturing too close to the fovea (see Sect. 30.3.2.).
- 19.
Or insist on his “my way” approach.
- 20.
While writing this book, I saw a patient who was injured while chopping wood. He suffered a scleral rupture, traumatic cataract, and a VH. His wound was sutured and the ophthalmologist immediately had his assistant refer the patient to a well-equipped institution. Unfortunately, the assistant making the phone call failed to mention that the referral is for a fresh injury and simply asked for an appointment; the receiving institution also failed to ask the reason for the referral. The patient was scheduled for the next available date, which was 4 months later. He arrived with LP vision and an incarcerated, totally detached retina with severe PVR.
- 21.
I remember a cornea book with over 1,500 pages – and that was in 1978. Imagine a book today on the same topic and with the same detail: how long would it be?
- 22.
As well as in many other subspecialties such as uveitis or the cornea.
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Kuhn, F. (2016). Fundamental Rules for the VR Surgeon. In: Vitreoretinal Surgery: Strategies and Tactics. Springer, Cham. https://doi.org/10.1007/978-3-319-19479-0_3
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