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GUEST EDITORIAL
Year : 2017  |  Volume : 29  |  Issue : 3  |  Page : 152-153

Evolution of retinal surgery - what are we heading to?


Department of Vitreo Retinal Services, Sankara Nethralaya Medical Research Foundation, Chennai, Tamil Nadu, India

Date of Web Publication30-Jan-2018

Correspondence Address:
Lingam Gopal
Department of Vitreo Retinal Services, Sankara Nethralaya Medical Research Foundation, Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kjo.kjo_54_17

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How to cite this article:
Gopal L. Evolution of retinal surgery - what are we heading to?. Kerala J Ophthalmol 2017;29:152-3

How to cite this URL:
Gopal L. Evolution of retinal surgery - what are we heading to?. Kerala J Ophthalmol [serial online] 2017 [cited 2018 Apr 24];29:152-3. Available from: http://www.kjophthal.com/text.asp?2017/29/3/152/224294



From the invention of direct ophthalmoscope by Helmholz in 1850 to three-dimensional (3D) heads-up vitreoretinal surgery now, the progress made in the field of management of posterior segment diseases of the eye has been nothing short of being phenomenal. Landmark events in this journey had been identification of retinal break as cause of retinal detachment (Gonin, 1920), buckling procedure (Custodis, 1949), popularization of indirect ophthalmoscopy (Schepens, 1951), pars plana vitreous surgery (Machemer, 1970), gases (Norton, Vygantas, Lincoff 1973), silicone oil (Cibis, 1962), and perfluorocarbon liquids (Chang, 1987).

The miniaturization and progressive reduction in the size of the vitreous instruments from 20 gauge to 23, 25, and 27 gauge have also been an important innovation. Coupled with wide-angle visualization system, they changed the approach to the management of retinal detachment significantly.

Developments have been swift forcing surgeons to relearn many things or face the prospect being left out.

Retinal detachments were traditionally buckled, and vitreous surgery was considered only in selected cases. Retinal detachments with peripheral break and macular hole were buckled, ignoring the macular hole. A 360° encirclage was considered a must along with a silicone buckle (at least according to Schepens school of thought). The shift from “primary buckle” toward “primary vitrectomy” approach in correcting retinal detachments was subtle to start with but has become acceptable and common now. This does not mean the buckle has been discarded. Surgeons do understand the continued role of scleral buckle in selected cases such as retinal detachments secondary to retinal dialysis, lattice with atrophic holes, etc. Surgeons are also critically evaluating the necessity or otherwise of adding an encirclage to the vitrectomy in correcting retinal detachments.

The scope of vitreoretinal surgery has expanded tremendously. Surgery for macular holes has become routine with excellent success rate. With increasing experience and confidence, surgeons are operating cases earlier, at a stage when the vision is still good, and the holes are smaller. Combining these macular surgeries with cataract surgery and intraocular lens implant has also become common, considering the frequency of some amount of cataract coexisting and the certainty of future progression of cataract.

The era of vitrectomy started with the removal of vitreous opacities in the form of simple vitreous hemorrhage and then spread to more complicated indications. We seem to have gone through a full circle. The newest indication for vitrectomy is removal of vitreous floaters – so-called floaterectomy.

In the area of retinopathy of prematurity (ROP), India presents a mixed bag of cases. On the one hand, we continue to get cases of stage 5 ROP in unscreened, relatively heavy babies, and on the other hand, we have APROP occurring in significant numbers due to uncontrolled oxygen administration in low birth weight infants - many of them subsequently developing stage 4 disease requiring surgical intervention. Hopefully, this situation will change with more uniform and better neonatal care leading to less demand on the vitreoretinal surgeons to manage ROP-related retinal detachments.

The traditional microscope oculars and head down position for surgeon are likely to change to the 3D-heads-up display. The perceived advantages of the system include, better posture for the surgeon, lower illumination required for visualization (potential reduced phototoxicity), better participation in the surgery from the assistants since all have the same view.

Antivascular endothelial growth factor drugs definitely revolutionized medical retinal practice - perhaps as much as photocoagulation did. The future of medical retinal practice could include forays into the field of gene therapy and stem cell therapies.

The vitreoretinal surgeons may act as a delivery system for these therapeutic modalities.

As a retinal surgeon, if I had a wish list for the future I would like to see most patients with retinal detachments presenting early in disease (not with closed funnel retinal detachments), excellent neonatal standard of care to reduce the load of ROP, good screening protocols to detect diabetic retinopathy early, good patient compliance, and ability to go through treatment without too much of financial burden (good quality public health system) and a healthy patient-doctor relationship.






 

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