Prof & Pupil: Retina Surgery 101 and Innovation in the OR [Part 1]

We're starting Prof & Pupil, a miniseries of posts, where Dr. Sridhar and I talk about different aspects of ophthalmology, retina surgery, and more! These are presented in conversation format (much like classic Greek philosophical texts), and we hope they'll be both enjoyable and quick to read! 

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Jay: Louie, you got the opportunity to observe some retinal surgery with me this past week. What was your first impression of what we do compared to other surgeries in medical school you have observed this past year?

Louie: Retina surgery is completely different from the surgeries I saw in trauma, colorectal, and OB GYN. I felt like from beginning to end, you knew exactly what you were dealing with based off the scans and photos. I felt that in other surgeries there is a lot of uncertainty about what you might encounter and what techniques you might have to employ. There's a lot of chaos- random bleeding, adhesions you weren't expecting, etc.. For retina surgery, at least from my perspective, it seemed like you had complete control from start to finish. The procedures were clean, systematic, and very precise. Maybe that's not how you actually felt while you were operating... haha. Also I notice you were using one sterile glove instead of two?

Jay: Yes, we rarely double glove although perhaps we should. Thankfully our needle exposure is not the same as other fields! That's flattering that you say that. Definitely the imaging technology has made our lives a lot easier. Still, what I love about retina surgery is no matter how much we try to control every detail, things can be unpredictable and you have to rely on good habits to approach unusual situations. What maneuvers appeared most challenging from the student perspective?

Louie: I think for me, the hardest part is definitely seeing how deep you are in the vitreous when you're doing a vitrectomy. You have to have very good stereopsis to perceive the depth correctly. I don't know if you've seen the movie Prometheus, but there's this scene where a drone goes into a cave and scans it with lasers. I always wonder how helpful it might be if your instruments could emit a grid of light around it, and you could judge exactly how far you are away from the borders. 

This is an image of what I'm talking about..  

Jay: that's a great point Louie. One of my mentors Dr. Allen Ho used to talk about a vision for the future of visualization during surgery. We already have products on the market such as the ngenuity from Alcon that allow for heads-up 3D display for surgery using a large TV monitor and 3D glasses. We also have OCT Technology built into our microscopes that allows us to see the retina in higher detail and with a greater perspective of depth and the retinal layers than ever before. People have discussed in the future having motion tracking or indicators to guide a surgeon much the way modern cars do with collision warnings.

Did you observe anything done in other fields that you think we should adopt in our surgical practice?

Louie: I think all those ideas are awesome. One of my favorite aspects about ophthalmology is that everybody in the field seems to embrace and actively seek ways to improve the status quo. The heads up display will literally turn the operating room into a video game! How quickly do you see people adopting new technology, from proof of concept to actual use? For example how long did it take for the vitrector to be put in every operating room?

I think the other surgeries have a lot more to learn from retina surgery actually! Haha but if there was one thing, I noticed that because of the scopes and positioning of the bed, it's easy to feel kind of cramped when you're sitting there (especially if you're tall). This isn't really a problem with other surgeries since you can stand and stretch and move around. I'm not sure how you could change that.

Jay: that's a great question about technology adoption. I think given globalization of information, sharing technologies and techniques are adapted faster and faster. The heads up display is already used as the sole visualization tool in a couple of practices and institutions nationally. Much like a viral video I believe it will spread more as more and more prominent surgeons go to meetings or webinairs and show cases using heads up viewing.

Definitely ergonomics is a challenge in our field. As a student I remember loving that the cases were mainly performed sitting down. However sitting puts your body in a fixed position which can result in stress on the head and neck. Developing good habits early in training at the slit lamp will help, but every person is a little different in terms of how their body fits with the foot pedals, the microscope, and the patients head position. There has been some debate whether robotic surgery similar to the Da Vinci used in other fields such as urology could eventually replace our current method of operating, but the jury is still out given a lack of evidence thus far.

Louie: That's really interesting and I look forward to trying those new tools! How many retina surgeries did you do throughout residency and fellowship, and how soon were you comfortable to handle cases on your own? In other words, how many cases do you have to do before you feel comfortable handling most complications?

Jay: I think the number of surgeries varies from fellowship to fellowship. Few residencies include much hands-on retina exposure although if you are able to obtain it, it’s an added bonus. The most important thing besides seeing lots of patients and scrubbing in lots of surgeries is learning strong principles from solid mentors. Every case is different; a retinal detachment and macular pucker, for example, are entirely different beasts in the way you approach them mentally in your pre-operative gameplan. So the number of cases to get comfortable really will depend on the pathology at hand.

 To be continued...