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UPFRONT: Improving Our Surgical Visualization

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“We can easily forgive a child who is afraid of the dark; the real tragedy of life is when men are afraid of the light.” — Author unknown

As retinal surgeons, we strive to obtain the best possible view during surgery. We upgrade our microscopes, use 3D visualization systems, and are even testing digital microscopes with VR headsets that offer image processing tricks to help us better visualize the surgical field. We teach our fellows to ensure there is appropriate alignment of the eye, lenses, and microscope, as well as aiming our lighting tools to aid in visualization. It is in these controlled surgical conditions that we are accustomed to working and obtaining our best results.

But what about situations where the view is compromised, such as in endophthalmitis, trauma, extensive hemorrhage, or anterior-segment abnormalities, such as dense corneal opacities? Many surgeons perform minimal, inefficient and often ineffective surgeries “blindly” or in some cases don’t operate at all for fear of making things worse. These cases offer extreme visualization difficulties and require unique solutions that many surgeons have not seen or been trained in.

For most surgeons, facility with endoscopes is not high on their list of surgical skills. Like operating under a microscope, this new visualization platform requires practice to become adept. But, once mastered, it can be a very powerful tool in these difficult situations. In this issue, we have a wonderful article on the use of endoscopes in the management of endophthalmitis, certainly one of the more difficult visualization surgeries we perform.

Similarly, operating through the small optic of the Boston Keratoprosthesis Type 1 requires tips and tricks of which most surgeons are not aware. We have many of these in Cleveland, and I can say surgery through them is difficult. In this issue, we also discuss the issues and solutions of operating in patients with this increasingly common condition.

On the other end of the spectrum, the use of combined cataract and macular surgery is the norm. There are many benefits to this approach, not the least of which is an excellent view to perform the macular work. There are many other benefits that are outlined in an article in this issue. I am a firm believer in this approach and perform most of my macular surgery combined. Unfortunately, the health care system has not caught on to the benefits and still penalizes us for an approach that has better outcomes for our patients. Time and additional studies will hopeful change this situation in the United States. RP

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