Vitrectomy evolution from concept to reality

Office-based vitrectomy is poised for making the transition from concept to reality, according to Tarek S Hassan MD, speaking at the 16th EURETINA Congress in Copenhagen, Denmark. Dr Hassan noted that the idea of performing vitrectomy in the office setting was first proposed 25 years ago. In the interim, the procedure followed a protracted course in moving from being done exclusively in hospital operating rooms (ORs) into ambulatory surgery centres. Compared with other surgical specialists, the vitreoretinal community has been particularly slow in taking the next evolutionary step, bringing vitrectomy into the office. However, thanks to a number of developments, the foundation for office-based vitrectomy is set, and the future is now. “There have been limitations in technology, safety, and the perception of safety that restricted the movement to office-based vitrectomy. Now the arguments have changed. What is needed is the willingness to break from old dogma and look to the inevitability of change in our surgical world,” said Dr Hassan, Professor of Ophthalmology, Oakland University, Michigan, USA. Arguments against office-based vitrectomy have cited inability to fully achieve surgical goals, insufficiency of technology, limited surgical indications, lack of sterility, inability to handle operative emergencies, and the lack of regulation and reimbursement. In his talk, Dr Hassan explained why all of those arguments are no longer valid. SURGICAL GOALS The idea that vitrectomy in the office cannot be done to achieve surgical goals was proven wrong almost 15 years ago by a published paper describing space and media clearing procedures performed safely and effectively in a series of 225 eyes. Subsequently, multiple reports have established the feasibility of office-based vitrectomy for an expanding list of indications. The idea that technology is insufficient for office-based vitrectomy is also wrong, as current platforms, including small, portable units as well as full-sized consoles, can be used in the office, Dr Hassan said. Moreover, he predicted that future advancements – including smaller instrumentation providing faster cutting, enzymatic adjuncts, heads-up visualisation systems, and even wearable headsets with 3D visualisation – will deliver even better functionality and safety to optimise attainment of surgical goals. The idea that insufficient sterility is a barrier to office-based vitrectomy is negated by consideration of the fact that many office treatment rooms are likely more sterile than hospital ORs in third world countries, where surgery is done with infection rates comparable to those in the Western world despite conditions that include open windows, unmasked staff, and reuse of “disposable” instrumentation. Further evidence of safety in terms of sterility derives from a prospective study of 37 office-based microincision vitrectomy surgeries in which the rate of vitreous contamination was only 2.7%, which is lower than the 22% to 32% rate that was reported for 25-gauge standard vitrectomy in the OR, Dr Hassan said. In addition, new laminar flow technology has emerged that is allowing any room to achieve OR-like sterile conditions. Inability to handle medical emergencies in an office-based setting is also not a concern. With the use of peribulbar anaesthesia and with appropriate supplies on hand, such situations can be addressed by a trained office-based staff, although some office settings even have anaesthesia support. Furthermore, office-based vitrectomy can be performed under general anaesthesia if there is an anaesthesiologist on staff, and operative retinal emergencies can be addressed when surgeons are using either the small footprint or full-sized consoles that are capable of being used in the office setting. Dr Hassan pointed out there are ongoing efforts focusing on regulatory oversight and reimbursement that are relevant for office-based vitrectomy. At least in the USA, there is now much greater oversight and accreditation or registration of office-based surgery practices coming from boards of medicine, departments of health, specialty societies, and other medical organisations. In addition, a manual presenting standards for office-based surgery practices was published by the Joint Commission in 2016. Tarek S Hassan: tsahassan@yahoo.com