Ferenc Kuhn - Vitreoretinal Surgery: Strategies and Tactics
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This book is exceptional in explaining not only when and how but also why vitrectomy is performed an additional focus that will help trainee surgeons to develop their own critical thinking. Uniquely, the books first part describes the life of the vitreoretinal surgeon to help residents decide whether the field is indeed suitable for them, and if yes, how they can chart their own course in the absence of a formal fellowship program.
The second and third parts discuss the fundamentals in VR surgery, such as the general philosophy underlying vitrectomy, equipment, examination, timing, anesthesia, the surgeons posture, and the organization of the operating room. The final two parts are dedicated to surgical strategy and tissue tactics, reviewing the principles of surgical maneuvers and the practical sides of diagnosis-specific issues. An appendix is also included, which offers additional guideposts for the aspiring trainee surgeon, including a description of how an ideal mentor should act in surgery. The book is written in an easy-to-follow format with bullet points and text boxes, and has well over 250 color images and line drawings as well as over 60 tables.
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Becoming a VR Surgeon
Variable | Cataract surgeon | VR surgeon | Comment |
|---|---|---|---|
Learning curve | Moderate | Very steep | For a VR surgeon the learning process is intense and it remains forever so |
Sleepless nights before or after surgery | Almost nevera | Occasionally | Preoperatively because the surgeon is not sure what the best surgical approach would be Postoperatively because the surgeon now knows he made the wrong choice and it resulted in an irreversibly poor outcome |
Difficulty in preoperative decision-making | Minimal | Moderate to extreme | For the cataract surgeon, the diagnosis brings an almost automatic solution, phaco and IOL implantation, and the timing is also obvious: as soon as feasible. For the VR surgeon , this can raise extremely difficult questions ; just think about a one - eyed patient who has retinitis pigmentosa and develops an EMP. If something goes wrong during surgery , the patient instantly loses ( some ) central vision in an eye that is already losing its visual field ; then there is the risk of postoperative complications. Conversely , if surgery is not done , the central vision will gradually and irreversibly decrease |
Consequences if the preoperative decision-making was erroneous | None to minimal | None to extreme | Just think of a patient with an injury that has a high risk of endophthalmitis ; you decide to do early PPV but a catastrophic ECH occurs intraoperatively |
Physical challenge intraoperatively | Minimal; mainly determined by how many cases the surgeon decides to perform on a given day | Can be significant | My longest case ( TKP - PPV for a severe injury in a young boy ) lasted 6 h and 23 min |
Mental challenge intraoperatively | Moderate | Moderate to intense | During cataract surgery the need to make a unique, major decision relatively rarely emerges, but in certain instances real challenges do exist (children, pseudoexfoliation etc.). In VR surgery , even in easy cases ( VH , see Sect. ), many decisions are required , and some of them , if they prove to have been wrong , result in irreversibly negative consequences |
Difficulty in intraoperative decision-making | Minimal to moderate | Minimal to severe | Cataract surgery has to a large extent been standardized. The inter-case variability is typically limited, and even if the tissue reacts differently to that expected, the solution is usually a readily available one. Even in an easy case , the VR surgeon must make several decisions that are individualized to that particular patient / eyeball. In more difficult cases the number of decisions can be almost infinite |
Tissue reaction to the surgeons action | Typically as expected | As expected or very different | The nucleus may be as soft as predicted or much harder. During vitreoretinal separation the retina may prove as resistant to traction as assumed or it may tear at the weakest traction force |
Consequences if the intraoperative decision-making was erroneous | Minimal to moderateb | Minimal to extreme | Certain errors can easily be corrected ( an equatorial retinal tear has been caused during too forceful PVD ); others can result in irreversible loss of vision ( tearing the fovea during EMP removal ) |
Expected success rate/prognosis | Very high/excellent | Low to high / good to poor | The cataract surgeon is disappointed if full vision is not restorede or not restored rapidlyf In certain pathologies ( macular hole , EMP etc .) excellent visual recovery can be expected if surgery is done well and early. In others ( PVR , submacular hemorrhage etc .) the success rate is low and / or the recurrence or complication rate high ( see Fig. ) |
Apparent success rate | Very high | Low | This is a bias , although it may not be obvious to the VR surgeon : his patients are much less likely to come back for longer - term follow - up if surgery was successful. His failures , on the other hand , keep returning |
Intraoperative complication rate | None to low | None to moderate | For the cataract surgeon, these complications are rare and mild, and even if they occur, the solution is usually at hand The VR surgeon faces an endless list of potential complications , some of which may be rare or severe enough not to have a readily available solution |
Postoperative complication rate | None to low | None to infinite | A stand - alone booklet can be written about the list of potential complications following VR surgery ( see Chap . ) |
Severity of early postoperative complication(s) | None to lowc | None to extreme | For the cataract surgeon, the only truly vision-threatening risk is endophthalmitis |
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