- 17 Sep, 2024
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Vitreoretinal Surgery Procedure
Vitreoretinal Surgery Procedure
Retina and Vitreous surgery procedure is a microsurgical skill and requires precise
hand-eye coordination to perform the task accurately.
There are cases where untrained surgeons have caused severe complications
and have led to either temporary or permanent damage.
This occurs when one takes on a surgery that is out of their capacity to perform.
Surgery training is a long process that comes with a lot of responsibilities and is the most frustrating
time of a surgeon’s career.
It consists of multiple steps but the overall requires practice in a controlled environment,
which means that the skills, if not trained properly, will have a high chance
of error when performing the actual surgery.
The overall aim of the surgical training is to improve the safety of patient care and also
allow the surgeon to learn how to handle complications, which rarely arise in a normal clinic.
With the advancement of imaging tools and devices, comprehensive information on the anatomy
and pathology of vitreoretinal diseases is obtained, resulting in increased success rates
using minimally invasive surgery.
Patients’ expectations for better visual and surgical outcomes have also increased,
which translates to a more complex surgical goal, and the complexity of diseases that are possible to be treated.
All of these demands have resulted in an increased demand for a good vitreoretinal surgeon with a promising future.
Role of Training in Enhancing Surgical Skills
The primary aim of any surgical training program is to inculcate essential surgical skills
and to avoid mistakes that affect surgical outcomes.
Surgical training may involve simulation exercises, cadaveric dissection,
and assisting experienced surgeons in the operating room.
However, the role of simulation and involvement in actual surgery on real patients are to be defined.
Simulation-based training is becoming more popular today.
With advancements in technology, various vitreoretinal surgeries are being simulated on model
eyes and virtual reality modules.
High-fidelity simulators provide an environment close to actual surgery,
and trainees can repeat procedures until they achieve proficiency.
Simulation training ensures no risk to human patients and is more flexible in terms of timing.
This can be a good option for busy postgraduate students and busy vitreoretinal
surgeons who wish to improve their skills.
Clinical and surgical observation is a traditional way of learning surgical skills.
A trainee can learn from observing procedures performed by experienced surgeons.
This can be followed by assisting the surgeon in various steps of surgery before going on to perform solo surgery.
This traditional way of learning is less expensive and ensures no risk to the patient
if the trainee is not performing surgery.
However, it is time-consuming and has the limitation of being able to learn only from surgeons
available at a particular location.
The most important points that are studied in vitreoretinal surgery procedure training
1- Anesthesia Considerations
During the vitreoretinal surgery procedure, the surgeon must be knowledgeable
about the appropriate delivery of anesthesia and the ventilatory management
of the patient is important to the conduct of the vitreoretinal surgery procedure.
The majority of patients undergoing vitreoretinal surgery are elderly and may have systemic
diseases (such as diabetes and hypertension) which increase the operative risk.
It is important to have a clear understanding of the patient’s preoperative medical condition
by coordinating with the patient’s primary care physician and/or specialist.
This may assist in determining whether certain patients may need medical clearance
from an internist or a specialist before surgery.
While a complete medical history and physical is required for all patients undergoing surgery,
the use of preoperative laboratory testing would be at the discretion of the primary care physician,
specialist, anesthesiologist, and/or surgeon based on the patient’s age and coexisting medical conditions.
While there are debates in the literature regarding whether all vitreoretinal surgery patients
require preoperative ECG and chest X-ray, these tests are generally required for elderly
patients and those with significant medical illnesses.
2- Surgical Techniques
The wide variety of vitreoretinal procedures can be broadly classified into those where there is the removal
of intraocular tissue or a foreign body or those that involve the repair of a retinal detachment or macular hole.
The different vitreoretinal procedures are each subclassified depending on the precise indication and extent of surgery.
Various instruments are required to perform vitreoretinal surgery.
The basic ones include a slit lamp, contact lens, three-way tap, overhead lamp,
and the vitreoretinal equipment.
3- Step-by-Step Surgical Procedure
Surgeons learn during vitreoretinal surgery procedures Step-by-Step a three-port pars plana vitrectomy.
The first step is to create a conjunctival flap and a partial thickness sclerotomy is made with an MVR
blade at the inferotemporal limbus to insert a 20-gauge infusion cannula.
A paracentesis incision is made at the superotemporal limbus.
Then additional sclerotomies are made, and infusion/injection cannulas are placed into the sclerotomies.
This provides a closed system for infusion of BSS and/or air to maintain intraocular pressure.
After the surgery, the patient is positioned either supine or lateral to the affected side.
All positions should provide access to the entire eye and the uninhibited infusion of balanced
salt solution (BSS) via the pars plana during the entire surgery.
Intraoperative Techniques For Vitreoretinal Surgery Procedure
Intraoperative techniques are the cornerstone of a successful vitreoretinal surgery procedure.
Given the complexity and delicacy of vitreoretinal surgery, a thorough understanding
of the following techniques is essential for a successful outcome.
1- Microscope Settings and Visualization
To perform a vitreoretinal surgery procedure successfully, the surgeon must be able to see the retina
and vitreous to a degree sufficient for the intended procedure.
Effective visualization provides the appropriate information necessary for each stage of surgery.
As important as the skill of the surgeon, the surgical microscope and the illumination
source determine the degree of visualization.
There are many different models of the microscope, but the surgeon must be familiar
with the controls of the microscope in use.
A basic understanding of the physics of microscope light can help the surgeon to manipulate the light effectively.
2- Scleral Port Placement and Entry
When inserting sclerotomy ports, one must plan and visualize the placement
of the instrument at its intraocular destination.
The angle and location of this entry will depend on the instrument’s anticipated course within the eye.
Ideally, the instrument should enter the sclera at an angle that is collinear with its path
toward the desired intraocular target.
3- Vitrectomy and Membrane Peeling
Core vitrectomy is performed in the central vitreous but must be conducted in a manner sufficiently
cautious to avoid complications in patients with posterior vitreous detachment.
Conversely, peripheral vitrectomy involves the removal of vitreous close to the retina,
maintaining sufficient distance to avoid iatrogenic retinal breaks but close enough
to aid in the management of various vitreoretinal conditions.
Safe and effective vitrectomy requires a comprehensive understanding of vitreous anatomy
and the pathogenesis and natural history of specific vitreoretinal conditions.
4- Laser Photocoagulation and Retinopexy
Laser photocoagulation and retinopexy essentially involve sealing retinal breaks with high-energy light.
This is traditionally used in treating retinal tears and lattice.
While there are marginal cases for which laser should be used,
it is generally best employed in treating retinal breaks that are located some distance from the macula.
In these cases, the intent is to create an adhesion surrounding the break,
essentially gluing the retina back in place to prevent subacute detachments.
Retinal breaks located between 3 and 4 disc diameters from the macula can be comfortably
treated with laser with no associated increase in cataract or visual field loss.
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