FEATURE ›› SURGICAL PEARLS

Sharing SURGICAL PEARLS

Personal gems from colleagues can help to refine and elevate your surgical skills.

BY SUSAN WORLEY, CONTRIBUTING EDITOR

Clinical pearls are an integral part of the lifelong education of every retina surgeon. These condensed, stand-alone bits of wisdom — gained from personal experience and often transmitted orally — provide steady contributions to the informal but essential store of knowledge that enriches a surgeon’s practice long after he or she has left the classroom. And, as most retina specialists are aware, this priceless knowledge isn’t transmitted solely from the more experienced to the less experienced.

“You don’t have to be a world famous retina surgeon or a full professor at a major medical center to have useful clinical pearls to offer,” says Lawrence S. Halperin, MD, of the Retina Group of Florida, and chair of the communications committee for ASRS. “Every retina surgeon possesses at least one or two clinical pearls that would be of value to his or her colleagues.”

Clinical pearls rank as true gems when bestowed by respected colleagues, and when they contain an idea or approach to surgery that possesses the power to change a surgeon’s way of thinking. Inspired by a new pearl, a surgeon may be encouraged to reconsider the wisdom of deeply ingrained habits or routine behaviors long enough to awaken to new possibilities. “More than once in my own practice, a small clinical pearl passed on to me by a colleague has literally transformed the way that I had done something hundreds or thousands of times previously,” says Halperin. For example, in the past when repairing retinal detachments (RDs), Halperin would surgically create a tiny hole in the retina to drain fluid before reattaching the retina. “I’d probably made this small drainage hole hundreds of times out of habit, until one day a colleague asked why I did it when it was possible to drain fluid from one of the existing tears that caused the detachment,” he says. Of course, I’d been aware of that option, but my colleague’s advice made me pause for a moment and rethink what I’d been doing habitually. Today, instead of intentionally making those holes 99% of the time, I probably choose to make them only about 5 % of the time. Clinical pearls can sometimes be more esoteric or complex in nature, but frequently they change our approach to commonplace situations we face every day.”

The following surgeons, from different regions of the United States and with varying years of professional experience, have graciously offered these surgical pearls.

G. BAKER HUBBARD, MD, PROFESSOR OF OPHTHALMOLOGY, EMORY UNIVERSITY SCHOOL OF MEDICINE
YEARS IN PRACTICE: 14

PEARL #1

For young myopic patients with shallow inferior retinal detachment (RD) due to atrophic holes, try a 510 sponge.

“In general, our field is moving away from scleral buckles (SB) for retinal detachment,” says Dr. Hubbard, “but there are some instances in which I think they are particularly helpful or useful. In young myopic patients with an inferior detachment — particularly when it’s a shallow detachment and one that results from atrophic retinal holes — I believe SB with a 510 sponge is the best choice. These patients usually have a nice clear lens and can still accommodate, and this approach gives you a relatively large indentation inferiorly, which allows breaks to be closed without causing a lot of additional myopia. These RDs often aren’t very bullous and external drainage often isn’t necessary. Tapping the anterior chamber before tying the sutures with 5-0 nylons and 8mm bites allows excellent indentation.”

PEARL #2

Suture sclerotomies when placing silicone oil.

“Modern small-gauge, sutureless, transconjunctival sclerotomies work beautifully in many circumstances, but not when you’re using silicone oil. I close all sclerotomies with a suture when using oil tamponade. Otherwise, oil droplets leak under the conjunctiva and are impossible to get out. When bubbles of oil accumulate underneath the conjunctiva, the resulting irregular surface can not only be a source of discomfort, but a cosmetic problem as well.”

PEARL #3

Avoid perfluorocarbon (PFO) for bullous fovea-splitting RDs.

“I prefer to make a retinotomy and completely remove all of the subretinal fluid when the RD is bullous and at or near the fovea. Macular folds occur when using PFO because subretinal fluid is sequestered anteriorly during laser. After the fluid-air exchange, the subretinal fluid collects posteriorly and can cause a macular fold to occur when the patient sits up. If all of the subretinal fluid is removed with internal drainage, through a retinotomy, this won’t happen.”

PAUL HAHN, MD, PHD, ASSISTANT PROFESSOR OF OPHTHALMOLOGY, VITREORETINAL SURGERY AND DISEASES, DUKE UNIVERSITY EYE CENTER
YEARS IN PRACTICE: 3

PEARL #4

Remember your feet.

“In contrast to many other surgical specialties in which the hands perform most of the work, vitreoretinal surgery also requires nuanced and constant footwork, including foot pedal-controlled adjustment of microscope positions,” says Dr. Hahn. “One tip I learned after joining Duke was to try wearing aqua socks, which can be purchased for as little as $10 at your local sporting goods store. These shoes are light, with a thin rubber sole, which provides the perfect balance of grip, sensitivity and protection. I leave a pair in my OR locker. They’re reliable and they sure beat clunky shoes or going shoeless.”

PEARL #5

Take a tactical approach to your ICG.

“I use indocyanine green (ICG) to peel the internal limiting membrane (ILM), but am always concerned about toxicity. I dilute my ICG from the standard 25-mg bottle in 25ml D5W (to a final concentration of 1mg/ml). The increased specific gravity allows the ICG to settle to the macula or other area of interest rather than diffusing throughout the vitreous cavity. I also immediately remove the ICG, and with small-gauge instruments, I recommend continuing to aspirate for an additional minute or so after you think everything has been removed. It may seem like nothing is happening during this time, but you’ll be removing residual ICG. If you examine the macula after that extra minute, you should appreciate increased contrast and visibility of the staining. This practice allows you to use less ICG and minimize risk of toxicity.”

PEARL #6

Expand your gas for inferior pathology.

“Successful retinal reattachment following vitrectomy depends on adequate tamponade.  For tears in the inferior quadrants, particularly if a scleral buckle isn’t placed, I recommend a complete vitrectomy followed by a slightly expansile gas concentration (I typically use 30% SF6 or 18% C3F8). I like to see IOP at postoperative day 1 in the mid 20s, which normalizes by the following week without IOP medications. The patient should have a complete gas fill for at least the first week, which is a critical complement to appropriate positioning for successful retinal reattachment. Unless a patient has severe end-stage glaucoma, slightly elevated IOP won’t blind anyone, but a recurrent detachment from inadequate tamponade can.”

STEVE CHARLES, MD, CLINICAL PROFESSOR OF OPHTHALMOLOGY, UNIVERSITY OF TENNESSEE
YEARS IN PRACTICE: 39

PEARL #7

Master and perform ILM peeling for a broad range of indications, and use grasping forceps for this procedure.

“The ILM is 3 microns thick — that’s half the size of a red blood cell — it’s transparent, and it’s extremely challenging to peel,” says Dr. Charles, “and perhaps for those reasons, many surgeons are reluctant to perform this procedure, except when they’re confronted with macular holes. However, other absolute indications for ILM peeling include vitreomacular schisis, epimacular membrane, vitreomacular traction syndrome, hypotony maculopathy, and macular folds secondary to incorrect surgical technique. It is critical to understand the highly elastic biomechanical properties of the ILM, and that ILM peeling guarantees removal of residual posterior vitreous cortex, and reduces recurrent epimacular membrane by eliminating attachment points for modified astrocytes. It’s also essential to use forceps membrane peeling, with true end-grasping forceps, such as the Alcon DSP ILM forceps. With the pinch peeling technique, no dangerous pics or diamond-dusted membrane scrapers are needed, and there’s no need to create an edge.”

PEARL #8

Use conformal cutter delamination for thicker, rigid, ERM and curved rather than vertical scissors.

“Many surgeons today seem to believe they no longer need scissors because of the fancy cutter systems available. However, it’s crucial to understand that scissors delamination is still required for broad areas of ERM-retinal adherence (tabletop tractional RD), and if you’re a fellow or a novice in practice, you must master the skills necessary to use scissors. Curved scissors are better than vertical scissors for all cases because the blade width is greater than the blade thickness; consequently, less space is required between the ERM and retina. Access segmentation with curved scissors is used to identify the delamination plane. The term “en bloc” is a misnomer; the goal isn’t removal of the ERM in a single piece; the goal is to minimize iatrogenic retinal breaks. Bimanual surgery and visco-dissection are unnecessary and overly complex. I developed both scissors segmentation and scissors delamination of epiretinal membranes, principally for diabetic traction retinal detachments. Foldback cutter delamination is potentially safer than conformal cutter delamination only for thin, flexible ERM. Conformal cutter delamination is required for thicker, rigid, ERM.”

PEARL #9

Master interface vitrectomy.

“Surgery under air and surgery under oil are techniques that are extremely crucial to learn and a tremendous number of fellows are leaving their training never having learned or tried them, and never having seen them, and that concerns me. Vitrectomy under-air applications include removal of vitreous traction during or after fluid-air exchange, confining profuse bleeding, retinectomy for anterior loop PVR, and punch-through retinotomy for forceps removal of subretinal bands. Retinectomy, which I first reported, is better than relaxing retinotomy, because all tissue anterior to the cut is removed, thereby reducing hypotony and PVR recurrences. Reoperation under oil is another form of interface vitrectomy and ideal for PVR and epimacular membranes.”

DR. PRAVIN U. DUGEL, MD, CLINICAL PROFESSOR OF OPHTHALMOLOGY, KECK SCHOOL OF MEDICINE, UNIVERSITY OF SOUTHERN CALIFORNIA
YEARS IN PRACTICE: 20

PEARL #10

Make sure you treat the patient.

“Sometimes we have a tendency to be more focused on the skill required for a procedure than on the patient,” says Dr. Dugel. “For example, we might forget that a patient under local anesthesia is awake and listening, and we sometimes say things we regret. It’s essential to remember the patient first and foremost. Remember that all patients are scared, no matter what, though they may have different ways of expressing fear. I begin every procedure by addressing the patient and recognizing that he or she may be afraid. I make a point of saying ‘I know you’re nervous. I’m here to take care of you, and I’ll do everything I can to make sure things go smoothly.”

PEARL #11

Never use the hand rest as a hand rest.

“I use the metal hand rest for one thing only: I allow it to simply catch water that drips down during surgery. I always make a point of resting my hands or palms on the patient’s forehead during surgery, and never on the hand rest. Since I do everything under local anesthesia, a patient will at times move his or her head, and when this happens, my hand moves along with it. If your hand is resting on the hand rest, your hand will be independent of your patient’s movement, which creates a very dangerous situation.”

PEARL #12

Always ensure that you have pristine visualization.

“You can’t cure what you can’t see and I firmly believe, with all the advances in surgery right now, one of the remaining gaps is visualization. I think we’re on the precipice of having new ways of visualizing the retina that will revolutionize our surgery. Until then, it’s important you always ensure that you have focus and always move the microscope in whatever manner necessary to get the best visualization.”

JOHN KITCHENS, MD, RETINA ASSOCIATES OF KENTUCKY
YEARS IN PRACTICE: 9

PEARL #13

You won’t regret the surgery you don’t do.

“A finding on OCT or during a clinical exam doesn’t always translate into a need for surgery, and you want to avoid an intervention that doesn’t make the patient better,” says Dr. Kitchens. “After the first few years of practicing, I found that when I had a dissatisfied patient, in hindsight it was often questionable as to whether the problem I’d addressed with surgery had truly bothered the patient in the first place. I’ve learned, with time, that if a patient is definitely in need of surgery, because of a retinal detachment or macular hole, for example, it will be obvious during the first examination. When cases fall into a gray zone — for example, a 20/40 asymptomatic patient with an epiretinal membrane, or a patient bothered by vitreous debris — it’s usually wise to consider observation. It’s important not to rush your preoperative examination, or proceed with surgery too soon, especially without clear evidence that something is truly bothering a patient. When a problem falls into the gray zone, you’ll never be sorry that you watched a patient for another visit or two, instead of going directly to surgery.”

PEARL #14

Never remove another surgeon’s oil.

“There’s an old saying that before you tear down a fence you had better figure out why it was built in the first place. The same holds true for silicone oil, which is typically in your patient’s eye for a reason.  When you see a patient with retained silicone oil that you didn’t place, be sure to learn why the patient needed oil in the first place before you consider removing it.”

PEARL #15

Stay in the present during surgery.

“Surgery should always have a very natural flow to it — it’s the one area of my daily life in which I’m rarely distracted by anything, and because it’s a very high-pressure situation, I find any distraction can quickly become a source of misery. When you stay in the present, you’ll find that you naturally stay in tune with what you’re doing, and ‘locked in’ so that you really don’t have to stop and think too much about what to do next. There should never come a moment when you arrive at a tough decision and can’t make it quickly. Slower surgeons often are over-thinking things due to a distraction, such as re-thinking a decision they made 5 minutes previously. Instead of living in the past or in the future, during surgery you really must stay in the moment.”

VINCENT S. HAU, MD, PHD, SOUTHERN CALIFORNIA PERMANENTE MEDICAL GROUP
YEARS IN PRACTICE: 3.5

PEARL #16

Be your own best scrub tech.

“As all surgeons know, the scrub tech can make or break a case,” says Dr. Hau. “We all have horror stories related to working with techs who had no idea what they were doing. Rather than depending so heavily on scrub techs and their unpredictable skill levels, it’s imperative to ensure that you can perform surgery independent of a tech, if necessary. It’s essential to know the instruments and equipment well enough to trouble shoot them yourself. You never know when you may be on-call, only to find that your favorite scrub tech isn’t available and you’ve been assigned to someone who can’t even identify the retina. Take the time during your fellowship training or during down time before cases to work with the scrub tech and learn about what they do.”

PEARL #17

If you think even once about suturing a sclerotomy site: just do it.

“We all know that having a good gas or oil fill is important in retina surgery. Why jeopardize all of your hard work by not taking the extra minutes to close a site with a single suture? Dealing with post-op hypotony or subconjunctival oil is much more challenging then throwing in a simple suture. Small-gauge surgery doesn’t always ensure that sclerotomies will be self-sealing, especially in older patients with thin and friable sclera and conjunctiva.”

PEARL #18

Remember that you control a patient’s perception of success.

“Taking the time to explain to a patient and family or friends the realistic expectations associated with a successful surgical outcome, including potential side effects and details regarding the recovery process, can make you a superstar from your patient’s perspective. I know I have one chance to do this properly, during pre-op meetings, and I always ensure that my patient is aware of the possibility of cataract formation, permanent damage or distortion that can’t be fixed even with successful surgery, the potential need for reoperation due to PVR, and the likelihood of pain and worse vision on post-op day 1. Patients also need to know it can take a few weeks or even a few months for the retina to completely heal. I always make use of pre-op fundus photos and/or OCTs to provide the patient, before and after the surgery, with objective proof of their condition and post-op improvement. When a patient has improper or unrealistic expectations of surgery, it can cause problems very quickly.”

A LIFETIME OF GATHERING PEARLS

It’s never too early to adopt the habit of seeking clinical pearls from respected colleagues, or the habit of generating your own pearls.

“Whether you began your training 5 years ago or 35 years ago, you’ll find that few specialties undergo the kind of rapid and dramatic changes that regularly impact the field of retina,” says Dr. Halperin. “And if you don’t keep learning and changing and adopting new practices in our field, you’re going to fall behind. If you want to remain state of the art, you can’t continue to practice the way you were trained. Clinical pearls from trusted colleagues can help you to stay on top of new clinical challenges and surgical approaches.” NRP