Protect the OR!

For many of us retina specialists, the OR is where we fell in love with the retina. Browse through our Rising Stars and One to Watch honorees, and you will see just how many admit that they were hooked after watching a membrane peel or foreign body removal for the first time.

However, like most relationships these days, it’s complicated. We might love the OR, but it doesn’t always love us back. A new study by Li and Adelman found that, between 2000 and 2021, the service volume experienced a statistically significant decrease for 20 of 38 retina procedures. While intravitreal injections increased more than 1,000-fold (remember, anti-VEGF agents came to market in 2006) and vitrectomy procedures increased from 71,039 to 95,429, panretinal photocoagulation declined from 104,865 to 48,533 procedures, and scleral buckling plummeted from 6,502 to 587 procedures.¹ Perhaps even more telling is the reimbursement: In the same timeframe, reimbursement decreased by a statistically significant amount for 29 of those 38 procedures.¹

The ongoing discussion of limited OR access for retina procedures—although rampant in conference halls—has yet to seep into the peer-reviewed literature, as it’s hard to quantify. Still, it’s adding even more pressure to those who practice in academic centers equipped to handle emergency cases. It’s also changing how we practice (choosing a tap-and-inject for endopthalmitis in lieu of vitrectomy, for example).²

Thus, retina surgery has become more of a labor of love than one might expect. Despite the grim aura surrounding reimbursement, surgical volume, and OR access, surgical intervention is often vital to preserve patients’ vision. And it’s an ever-evolving field with an onslaught of cool innovations poised to change the field forever. In fact, retina surgery is booming.

As we write this editorial, we are also filling our calendars with AAO Retina Subspecialty day sessions, and we cannot wait to learn about eye transplant surgery, office-based surgery, modern vitrectomy platforms, the growing field of robotic surgery, the use of amniotic membranes in vitreoretinal surgery, and novel secondary IOL techniques, to name just a few. There are also lectures on the latest surgical approaches to historically medically managed (or not managed at all) diseases, such as AMD, diabetic macular edema, and macular telangiectasia type 2. We are innovating in the OR more than ever before.

In this issue, we laud the grit and creativity that defines the retina OR—the reason we still do what we do. Stratos Gotzaridis, MD, FASRS, and Niki Zabogianni, MD, discuss the best techniques to ensure anatomic and functional success after retinal detachment repair (hint: Slower reattachment is better!), and Avni P. Finn, MD, MBA, and David L. Zhang, MD, provide a wonderful atlas of internal limiting membrane flaps to consider for macular hole repair. Jason Hsu, MD, and Sidra Zafar, MD, share pearls for handling proliferative vitreoretinopathy in the OR, and William E. Smiddy, MD, details the various ways to adapt scleral fixation for nearly any IOL style. Lastly, Audina M. Berrocal, MD, and Daniel A. Balikov, MD, PhD, describe several cases that benefitted from intraoperative OCT.

These are all new approaches our colleagues are implementing in their ORs right now, and we hope they reinvigorate your own curiosity and drive to innovate and improve our surgical practice. The more we improve outcomes, preserve patients’ vision, and treat those who used to hear “sorry, there’s nothing we can do,” the more weight we have when advocating to save our OR times and increase reimbursement rates. It’s a win-win—for us and our patients.