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Surgical success

Cutting-edge treatment does not happen by itself, says Leigh Spielberg MD, who recently saw history being made

Leigh Spielberg

Posted: Saturday, September 1, 2018

Fanny Nerinckx has always said that one of the main reasons she had come to work in Ghent University Hospital was to become involved in the treatment of retinal genetic disorders. In Ghent, she found the perfect place. The chairman of our department, Professor Bart Leroy, has built a well-known genetics department, receiving retinal degeneration referrals from across the country and beyond. Until recently, none of these patients could be treated. But recent developments in gene therapy and surgical implants have changed the landscape. So, Prof Leroy, needing an experienced retinal surgeon to help him take the next step, reached out to Dr Nerinckx. It has been a perfect match.
Seeing her chance, Dr Nerinckx decided to set her sights on an epiretinal implant. However, cutting-edge treatment doesn’t just organise itself. Yes, there are patients who are eager to participate; yes, the necessary expertise is present; yes, the manufacturer is always keen to supply an implant or gene-therapy meds. But there’s a lot of co-ordination required to make it all fall into place. Co-ordination and teamwork. A lot of teamwork.
Communication had to be opened between the genetics/electrophysiology department and the vitreoretinal department. Of the many patients in follow-up by the genetics team, a patient had to be selected who suffered from retinitis pigmentosa with light perception in both eyes and had otherwise normal optic nerves. No problem. But this was just the tip of the iceberg.
SecondSight, the producer of the Argus II retinal implant, also had to invest time, money and expertise. The university hospital’s ethics committee had to approve the surgery. And the hospital’s financial department had to agree to cover the surgical costs, which are not yet reimbursed by the national health service for this indication. We would need a special microscope with intraoperative OCT capabilities. A surgeon with implant experience would have to be present to guide Dr Nerinckx through the procedure. And Dr Nerinckx selected the anaesthesia team and the operating room nurses who would assist on the day of the surgery.
The work wouldn’t end with implantation. The hospital’s Low Vision department had to be willing and prepared to teach the patient how to use the implant, and our ophthalmology department’s personnel had to be instructed how to direct the phone calls, inquiries and patient referrals that would suddenly appear after news of the implantation had reached a wider audience.
After many months of preparation, the big day had finally arrived. The surgery itself would be a multi-step combination of scleral buckling, vitrectomy, ILM-peeling and implant placement. In particular, flawless placement of the “tack”, which would fasten the implant to the retina, was crucial. Erroneous placement might insufficiently stabilise the implant, tear the retina or induce choroidal haemorrhage. But Dr Nerinckx had spent many hours practising this step on a silicone model, and she was ready.
On the morning of the surgery, we entered the OR together.
Along the left wall, the three nurses readied the enormous amount of necessary material. Along the back wall, the two representatives from SecondSight were setting up the computer equipment required to final-check the implant’s software. A technician from Zeiss was final-checking the microscope’s built-in OCT. Two DORC vitrectomy employees were double-checking the vitrectomy machine so nothing unexpected would occur.
On the medical end, we had recruited the head of our OR’s anaesthesia department, Professor Marc Coppens, to make sure the patient’s vital signs, particularly the blood pressure, stayed perfectly stable throughout the procedure. Dr Pierre-Olivier Barale of Paris, a veteran of 12 implants and trainer of many others, was ready to go, while Sandra Vermeirsch, a third-year ophthalmologist-in-training, helped co-ordinate many of the details. My role as Dr Nerinckx’s vitreoretinal colleague was to maintain an overview of all that was going on in the operating room so that she could focus on the procedure.
The atmosphere in the OR seemed tense as the surgery got under way, but Dr Nerinckx was relaxed and assured. The surgery proceeded flawlessly. There was a palpable release of tension as the implant was tacked to the retina and the intraoperative OCT showed perfect approximation of the electrode array. A year of preparation had gone into this moment and it had all come down to this: success.
Dr Nerinckx looked at me and I could see her smile behind her mask. It had all clearly been worth the effort.
The surgery was the first such in Belgium, and made the national news headlines soon thereafter. Since the implantation, the patient has learned to identify objects that are high-contrast compared to the background, such as tableware and door handles. She can recognise pedestrian crossings and observe moving objects, which will allow her to cross the street safely and independently. Fascinating.

Dr Leigh Spielberg is a vitreoretinal and cataract surgeon at Ghent University, Belgium