Trends and emerging patterns of practice in vitreoretinal surgery

Editor, V itrectomy surgical techniques have rapidly developed over the last 15 years and continue to evolve with the introduction of perfluorocarbon liquids, multifunctional probes, improved endoillumination and sutureless microincision vitrectomy. In the context of rhegmatogenous retinal detachment (RRD)management, there is a decline in buckle surgery (El-Amir et al. 2009) and shift towards pars plana vitrectomy (PPV) as the procedure of choice. Other established indications for PPV include macular hole (MH), epiretinal membrane (ERM), non-clearing diabetic vitreous haemorrhage (NCVH), tractional retinal detachment (TRD) with variations in gases used, posturing regime and vital dyes. The surgical episodes for all patients having vitreoretinal procedures at three sites (St Thomas’ Hospital, London Eye Clinic, Queen Mary’s Hospital, United Kingdom) under a single surgeon were anonymized and prospectively recorded on an electronic medical record (Vitreor, AxSys Technologies, Glasgow, UK) between January 1997 and December 2013 and is being reported. Included in the study are data on baseline primary indication, details of surgical procedure, method of anaesthesia and intra-ocular agents. Two-sided t-tests and Pearson correlation were performed to test for slope, and all p values are presented with a Bonferroni correction. There were 7570 operations in 5591 patients (1.35 operation per patient), ratio of males to females (1.27:1), the mean age was 59.8 years (SD, 170.0 years), and 48.8% of operations were on left eyes and 51.2% on right eyes. The most common indication for surgery was RRD (42.8%) followed by intervention for vitreous haemorrhage (VH) (12.6%), TRD (6.1%), MH (10.4%) and ERM (7.7%). The relative frequency of vitreoretinal surgical intervention for most indications has remained similar over the past 16 years. In the management of RRD, 82.6% of the cases were pars plana vitrectomy procedures, and 16.6% were external buckle procedures with an increasing pattern towards PPV as the preferred choice (r = 0.229. R = 0.052, p < 0.001) (Fig. 1). The percentage of cases undergoing PPV, as compared to explant surgery, has increased from 60% in 1997 to over 90% in 2013. Macular hole surgery increased as a relative proportion of all cases (r = 0.95, p < 0.013) over the 16 years, and there was increasing use of hexafluoroethane (C2F6) as a tamponade agent following its introduction in 2009 rather than perfluoropropane (C3F8: r = 0.508, r = 0.252, p < 0.001). This trend in preferential use of C2F6 over C3F8 was also seen for other indications in later years. There was an increasing trend for combined lens and vitreous (CLV) extraction with PPV for the management of ERM andMH (Fig. 1). Brilliant blue is increasingly being used to stain internal limiting membrane in macular pathologies and was preferred over trypan blue. There was a general increasing preference for local anaesthesia across all surgical indications with time (p < 0.001). This study presents one of the largest series in the literature of patients who underwent vitreoretinal (VR) surgery over a prolonged period of 15 years. Overall, this study demonstrates that there is a move towards vitrectomy for both phakic and pseudophakic RRD. It is similar to increasing use of small