Vitreoretinal Surgery
Vitreoretinal surgery as a sub-specialty of ophthalmology has evolved rapidly in terms of training and professional practice as well as in a technical sense. Until the 1990s, primary surgery for retinal detachment was widely regarded as being within the capability of the general ophthalmologist. Today, surgery for retinal detachment and other vitreoretinal disorders is almost exclusively carried out by ophthalmologists who have had additional sub-specialty training in vitreoretinal surgery beyond what is required for the Certificate of Completion of Training in ophthalmology.
During most of the 20th Century, surgical techniques for retinal reattachment consisted largely of interventions carried out from the scleral surface of the eye (eg buckling, sub-retinal fluid drainage, cryotherapy) which made conditions favourable for the retina to reattach itself. The skills required for these procedures were to some extent transferable from those required for squint surgery.
In the early 1970s, novel instruments and techniques were developed for removing the vitreous gel through small openings in the pars plana of the ciliary body. The advent of vitrectomy combined with internal tamponade of the retina using gas or silicone oil made possible the repair of types of retinal detachment that had hitherto been refractory to external techniques. As techniques and instruments became more sophisticated, vitrectomy gradually superseded external buckling procedures for the primary repair of most retinal detachments. This change in practice has been accompanied by a steady increase in the rate of successful retinal reattachment.
Alongside these developments, it has become possible to treat a range of retinal pathology such as epiretinal membranes, macular holes and the fibrovascular complications of proliferative diabetic retinopathy using vitreoretinal surgical techniques.
Vitreoretinal surgery continues to evolve rapidly as a sub-specialty. Advances in surgical practice have led to an improved understanding of the pathophysiology of many diseases of the eye, which in turn continues to stimulate further developments in surgical technique.
Vitreoretinal surgery is technically demanding, requiring high levels of manual dexterity. It can also be physically and mentally demanding as more complex procedures can sometimes take several hours. A typical job plan for a vitreoretinal surgeon tends to consist of a larger number of surgical sessions and a smaller number of outpatient sessions than job plans for most other ophthalmological sub-specialties.
One of the major challenges for vitreoretinal services is balancing the competing demands of the emergency and elective components of the workload. Retinal detachment remains the most common vitreoretinal emergency and although surgery should be ideally be scheduled within 24 hours for situations where the fovea has not yet become detached but is threatened, it can be very difficult to achieve this ideal consistently, particularly in areas which are a long distance from a centre with the necessary facilities. Only the largest ophthalmology units have enough vitreoretinal surgeons to provide continuous cover for surgical emergencies. Smaller units may only be able to provide urgent treatment of vitreoretinal emergencies during weekdays and may be obliged to refer patients who present at weekends to a tertiary centre for instance. It is important that each ophthalmic unit has a clear policy for the management or onward referral of vitreoretinal emergencies.