Small-gauge Surgery in Vitreoretinal Disorders – There is More than Meets the Eye
European Ophthalmic Review
The impact of ageing-associated diseases has increased exponentially due to the known factors of longer life expectancy (the 'silver tsunami'), greater demands by the elderly for a good quality of life and the progress and increased availability of diagnostic and treatment options. In this era of consumerism, patients are overwhelmed by information from all sides -whether it be doctors' recommendations, dissenting experts, confusing statistics or testimonials on the Internet -and are therefore
... ore involved in the decision-making process with potentially expanding medical-legal controversies. The classic model of medical decision-making based on economic theory developed by the mathematician Daniel Bernoulli became unsatisfactory and problematic in medicine where outcome and utility are not measurable in money. We should ask healthy people how much they think a given medical condition would affect their quality of life. Some people are maximalist and want everything done; others are minimalists who desire the least treatment necessary. Another group take a naturalist approach, looking for natural solutions and, finally, there are the believers who are certain that they will find a good solution for their condition. Both patients and physicians are deeply influenced by dramatic stories. Vitreoretinal surgery may carry an elevated risk of complications because we work on tissue with a thickness of microns. 1 We are living in an age of an accelerating information explosion and visual tasks are becoming more compelling thanks to the widespread diffusion of smartphones, tablets and personal computers. Furthermore, patients continue to drive in their eighties and nineties. The impact on the patient's life of distressing symptoms, such as visual distortions or floaters, is comparable with a loss in lines of visual acuity. In this direction, the criteria used to offer surgery are also changing. The visual acuity thresholds are only one step in the decision-making process. We may also operate on patients who retain good visual acuity in terms of quantity, but who are not comfortable with their quality of vision. Another matter to be taken into account is the increased volume of cataract surgery. The skills and the expertise in vitreoretinal surgery techniques are becoming of fundamental importance in managing vitreoretinal complications during, or after, complicated cases of cataract surgery. We believe that a cataract surgeon should have some vitreoretinal training and vice versa. In Italy, almost all vitreoretinal surgeons also perform cataract surgery. In our hospital in Torino, we perform combined cataract and vitrectomy surgery in complicated cases and in patients over 65 years old with macular pathology. However, diagnosis-related group-based (DRG) reimbursement does not include cataract surgery and vitreoretinal surgery in the same procedure: our clinical goal is to only take our patients to the surgical theatre once in patient-orientated surgery. 2-4 Historically, the most common surgical platforms for vitrectomy surgery, since its introduction in 1997, have been the Alcon Accurus ® and Bausch & Lomb Millennium ® vitrectomy systems, followed by DORC platforms. In parallel to the technological progress of vitrectomy platforms and small-gauge trocar systems, the new concepts of core vitrectomy and full vitrectomy emerged according to the vitreoretinal pathology, macular conditions or retinal detachment, respectively. The philosophy behind the choice of the core or central vitrectomy benefited from dye-assisted vitrectomy and from our improved knowledge of the role of the vitreous in a healthy retina. We thought that 23-gauge could be the standard in vitreoretinal surgery when coupled with the Accurus or DORC platform systems. 5,6 However, when we pioneered 23-gauge surgery, we experienced an increased rate of retinal detachment following macular surgery. 7 Furthermore, we registered an increased rate of endophthalmitis 7 in comparison to 20-gauge surgery, mainly centred on wound stability and imperfect architecture of sclerotomies. Nonetheless, we thought that we were right. We were sure that a new technological revolution was coming in the ophthalmology world and that a transition towards the 'small calibre is better' paradigm would be the future. The recent introduction of high-speed 25-gauge vitrectomy systems with duty cycle has not only allowed less trauma for the patient with speedier recovery and a decreased rate of surgical complications, but also the opportunity to complete surgical manoeuvres in a safer way with less risk of retinal tractions. The idea that 'one size fits almost all' is becoming true and may be translated to the everyday surgical practice.