Vitreoretinal Surgery: Strategies and Tactics

548 Pages·2016·20.745 MB·English

by  Ferenc Kuhn (auth.)

Ferenc Kuhn
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Vitreoretinal Surgery: Strategies and Tactics
Selected wisdoms for the aspiring VR surgeon
Vitreoretinal surgery: the easy thing that is hard to do (paraphrasing Bertold Brecht).
Even a journey of a thousand miles begins with a single step (Chinese proverb).
Anyone who has never made a mistake has never tried anything new (Albert Einstein).
The reception of outlandish ideas: First, “it’s completely impossible.” Second, “It’s possible but
not worth doing.” Third, “I said all along that it was a good idea”. (Sir Arthur C. Clarke).
If I had had listened to my customers, I would have improved the horse and buggy
(Henry Ford).
You can resist an invading army, but no power on earth can stop an idea whose time
has come (Victor Hugo).
The important thing is not to stop questioning. Curiosity has its own reason for existing
(Albert Einstein).
The difference between good and almost good is like the difference between the lightning
bug and lightning (Mark Twain).
Everything should be made as simple as possible, but not simpler (Albert Einstein).
Simplicity is the ultimate sophistication. It takes a lot of hard work to make something
simple (Steve Jobs).
What you see is what you get. What you don’t see gets you.
Hobson’s choice is a free choice in which only one option is offered.
Decisions are easy when no options are left (Narasimha Rao).
Doubt is not a pleasant position but certainty is absurd (Voltaire).
The surest sign of insanity is being certain without having any doubt (Andrew Feldmar).
Self-delusion is the fi rst step towards disaster (Raghuram Rajan).
Having a bad strategy is better than not having a strategy at all (Sir Winston Churchill).
No battle plan survives the fi rst contact with the enemy (Helmuth von Moltke).
We either fi nd a road or we build one (Hannibal).
They said it couldn’t be done, but that doesn’t always work.
Insanity is doing the same thing over and over again and expecting different outcomes
(Albert Einstein).
Do not fear to be eccentric in opinion, for every opinion now accepted was once eccentric
(Bertrand Russell).
What was yesterday’s gold standard is today’s dogma; what was yesterday’s craziness is
today’s gold.
You are neither right nor wrong because the crowd disagrees with you. You are right
because your data and reasoning are right (Benjamin Graham).
You cannot learn to play the piano by going to concerts.
Don’t pay attention to the critics. Don’t even ignore them (Sam Goldwyn).
Care more particularly for the individual patient than the special features of the disease
(Sir William Osler).
Ferenc Kuhn
Vitreoretinal Surgery:
Strategies and Tactics
Ferenc Kuhn, MD, PhD
St. Johns, FL
USA
Helen Keller Foundation
for Research and Education
International Society of Ocular Trauma
Birmingham, AL
USA
Consultant and Vitreoretinal Surgeon
Milos Eye Hospital
Belgrade
Serbia
Consultant and Vitreoretinal Surgeon
Zagórskiego Eye Hospital
Cracow
Poland
ISBN 978-3-319-19478-3 ISBN 978-3-319-19479-0 (eBook)
DOI 10.1007/978-3-319-19479-0
Library of Congress Control Number: 2015947620
Springer Cham Heidelberg New York Dordrecht London
© Springer International Publishing Switzerland 2016
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Preface: Read me First1
Even in the digital age, books printed on paper remain popular with readers.2
They are a great collection of knowledge presented in a concise, edited format.
Scientifi c books in particular offer a single source of expert opinion, typically richly
illustrated, and they continue to provide the reader the magic of holding a physical
copy in his hand. A book can be carried around and be accessible even in areas with
no internet service.3
Today’s scientifi c books are typically written by multiple authors, typically with
very limited editing.4 With occasional exceptions, each chapter in each book ends
with a long list of references,5 seemingly providing support for every major claim
the chapter makes. While such books have obvious merit, V itreoretinal Surgery:
Strategies and Tactics is different.
This book was written by a single author, refl ecting his over-30-year experience
in the fi eld. Crucially, this author claims neither that his approach to vitreoretinal
(VR) surgery is the only nor the best option; many surgeons will fi nd parts of this
book objectionable or have a different (better) solution to a particular problem than
the one described here.6
W hy this author has chosen to present that particular option for a particular
pathology at this particular point in time,7 however, does have a reason. It is the
1 See the Appendix, Part 2.
2 They do not necessarily compete with electronic versions either, as this book proves.
3 This is true even though an online (electronic) version has its own advantages, such as being fully
searchable. A hybrid between a printed and an online book is one available on an electronic reader
(iPad, Kindle), which is easy to carry around.
4 It is rather common to have the same topic addressed by more than one author in an edited book,
and the information is all too often contradictory.
5 Sometimes a chapter has more pages dedicated to the references than to the main topic itself.
6 L et me illustrate this point with one example: reoperation in eyes with silicone oil tamponade and
the need to keep the oil after surgery. I used to do the membrane removal under oil, but abandoned
this because, among others, I want to see the true (“oil-free”) anatomy of the retina in order to
address all abnormalities and because with the silicone oil freshly implanted, the “emulsifi cation
clock” is reset. Other surgeons, perhaps just as reasonably, will argue in favor of working under the
original oil.
7 The solution to a specifi c problem evolves over time; what has been true for a number of years
may not be true tomorrow as new options, techniques, and technologies emerge.
v
vi Preface: Read me First
author’s responsibility to describe not only w hat he does, h ow he does it, and w hen
he does it; above all, he must explain why he does it. The reader will then have an
opportunity to contemplate that “why” and make a conscious decision as to whether
he agrees and so will employ it himself or, again based on a conscious thought pro-
cess, decide against it – just as well, as long as the decision against is not a
random one.
T his book has no references, only a few important publications are listed as
“Further Reading.” References in the internet age are nowhere near as important in
a book as they once were. Besides, the statements made, the issues emphasized, the
surgical solutions offered in this publication represent a synthesis of the author’s
experience. What is described here may have as its birthmother his own brain, that
of a colleague during an informal conversation, a publication, or a presentation at
some meeting; either way, the original idea has surely evolved over time.
T his is a very practical-oriented book, presenting the reader with both strategic
and tactical questions about VR surgery (and the surgeon himself). Everything in
this publication serves as an agent provocateur to incite the reader to develop his
own, individualized approach to each patient, to each surgery. It is not the goal of
the book to create copies of the author-surgeon; it i s a goal of the book to encourage
the reader to make conscious decisions before, during, and after surgery,8 to develop
his own, unique method for working as a VR surgeon. The author recommends
spending a few minutes by listening to a wonderful song9 that so beautifully, so
elegantly describes this singular approach (the lyrics are also published at the end of
the Preface).1 0
The format of this book is rather unusual. The reader will fi nd few lengthy para-
graphs; these are mostly replaced by bullet points, tables, and text boxes such as
Pearls and Q &A. This format hopefully makes it easier to read the book and fi nd the
necessary information fast. Furthermore, the book is partially written in the fi rst
person1 1 and refers to the surgeon and the patients as “he”1 2 – for no reason other
than simplicity.
I tried to mimic as much as possible the most ideal teaching situation: an experi-
enced surgeon actively assisting the fellow. This requires providing specifi c advice
as the fellow progresses with the case and questions/issues arise. My own approach
to VR surgery is a very conscious one. This helps me foresee many of the problems
8 A good example is a recent lecture the author heard: the speaker described a diabetic patient
receiving 36 monthly injections into a single eye with macular edema. Obviously, the treatment
became an automated process, and the ophthalmologist forgot to stop at some point during the 3
years to look at the big picture, and ask: Isn’t there something wrong here if the patient must come
back for the very same thing every single month for 3 years and the pathology recurs every time?
9 https://www.youtube.com/watch?v = 6E2hYDIFDIU
10 An honest speaker asks his audience of trainees not to believe a word he (or anybody else) tells
them. They should carefully listen to what they are told, test the teaching in their own practice, and
then decide whether they accept, reject, or modify it.
11 Rather than, as is typical, the author referring to himself in the third person.
12 Except the OR nurse, who is a “she.” I have worked, throughout my career, very closely with 17
nurses, each a female.
Preface: Read me First vii
that emerge as surgery is performed by the fellow (or myself). I tried to construct
this book as if addressing these questions while assisting a younger colleague.
Naturally, not all situations can be anticipated and thus described in the book, but I
believe the most common ones will have been.
I attempted to structure the contents so that they follow a rational order and avoid
repetition as much as possible. However, I am aware that this is an impossible task.1 3
I also made an effort not to present information a well-trained, past-residency-
training ophthalmologist (aspiring to be a VR surgeon) is supposed to already know.
T he opening part is a rather unique one since it discusses issues that are virtually
never raised: who should and who should not be a VR surgeon, and how to train to
become one in a country without a formal fellowship. This part is followed by two
parts about the basic rules the surgeon must keep in mind before the actual surgery;
the fourth part deals with the fundamentals of VR surgery, while the fi fth is dedi-
cated to tactical issues per indication.
I do not recommend that the reader go straight to a chapter in the last two parts
of the book without reading (all) the prior parts fi rst; the chapters in Parts 4 a nd 5
were written with the assumption that the reader had gone through all preceding
chapters.
The book is based on the “standard 3-port” approach to vitrectomy, using the
microscope and the BIOM (macular contact lens) for viewing. One chapter ( 1 7 )
briefl y describes the alternative approaches. All issues discussed relate to 23 g trans-
conjunctival vitrectomy, unless otherwise indicated.
The book is not written for fellows residing in any specifi c country. While VR
surgeons in countries with an advanced health-care system may fi nd certain aspects
of what is discussed here superfl uous, 14 young surgeons in many, less advanced
countries are likely to have to deal with such issues. Furthermore, even in advanced
countries it is still helpful for the fellow to consciously address every possible com-
ponent of VR surgery, from the correct posture during surgery to using the forceps
in the most ideal way.1 5
The primary target audience of this book is the ophthalmologist who is either
contemplating whether to become a VR surgeon or who is already in training,
whether as part of a formal fellowship or, more commonly, an informal one. I sin-
cerely hope, however, that the book will also be useful to my very experienced col-
leagues: the training of the VR surgeon is never complete. Throughout these 3
decades I have visited numerous ORs and without exception found some “trick”
that was interesting so that I have decided to try it myself – or something that made
me murmur to myself: “thank God I never tried this.” Either way, the visit proved
13 Eventually, a choice has to be made between “vertical” and “horizontal” structuring. For exam-
ple, one cannot group everything that concerns the lens in a single location; the lens has to be
mentioned in the chapter on visibility as well as in several chapters dealing with strategy and
tactics.
14 Describing the characteristics of “the” ideal chair for vitrectomy, setting up the vitrectomy
machine etc.
15 At what angle should I peel the ILM in an eye with severe macular edema?
viii Preface: Read me First
useful: whatever it is that forces a surgeon to make conscious, rather than auto-
mated, decisions during surgery is a positive thing. The most important is for the
surgeon never to be on autopilot; he must avoid making decisions and surgical
maneuvers based on refl ex or custom.
In summary
Scientifi c books are impersonal – this book is not. They typically have mul-
tiple authors – this book has only one. They contain page after page of refer-
ences – this book presents none, only a list of “Further Reading”. They usually
address larger issues, not technical details – this book attempts to do both.
My Way lyrics:
And now, the end is near;
And so I face the fi nal curtain.
My friend, I’ll say it clear,
I’ll state my case, of which I’m certain.
I’ve lived a life that’s full.
I’ve traveled each and ev’ry highway;
And more, much more than this,
I did it my way.
Regrets, I’ve had a few;
But then again, too few to mention.
I did what I had to do
And saw it through without exemption.
I planned each charted course;
Each careful step along the byway,
And more, much more than this,
I did it my way.
Yes, there were times, I’m sure you knew
When I bit off more than I could chew.
But through it all, when there was doubt,
I ate it up and spit it out.
I faced it all and I stood tall;
And did it my way.
I’ve loved, I’ve laughed and cried.
I’ve had my fi ll; my share of losing.
And now, as tears subside,
I fi nd it all so amusing.
To think I did all that;
And may I say – not in a shy way,
“Oh no, oh no not me,
I did it my way.”
Preface: Read me First ix
For what is a man, what has he got?
If not himself, then he has naught.
To say the things he truly feels;
And not the words of one who kneels.
The record shows I took the blows –
And did it my way!
Yes, it was my way.
(by Jacques Revaux and Gilles Thibault)
Ferenc Kuhn , MD, PhD
Birmingham, AL, USA
Belgrade, Serbia
Cracow, Poland