Study Shows Surgical Skill Key to Macular Surgery

Manikin Simulation
Ophthalmology Surgery, Pasteur 2 Hospital, Nice, France, simulation center enabling interns to practice on mannequin to perfect technique, intern practices a retinal detachment operation, virtually. (Photo by: BSIP/Universal Images Group via Getty Images)
Damage to the structure and function of the inner retina correlates to surgical experience, an investigation shows.

Increased surgical experience is associated with better outcomes during macular surgery, including less structural and functional damage. From a technical perspective, more highly skilled surgeons are less likely to induce inner retinal damage via forceps, which is a common complication during the initiation of internal limiting membrane (ILM) peeling in macular hole surgery, according to a retrospective study published in Acta Ophthalmalogica. 

Investigators retrospectively assessed 3 macular hole case series more than 1 year after pars plana vitrectomy (PPV), ILM peeling, and gas tamponade. The case series included 32 surgeries done by 3 specialists: a novice surgeon (<20 cases), an intermediate surgeon (150+ cases), and an experienced surgeon (2000+ cases). The primary endpoint was inner retinal volume defect as segmented from optical coherence tomography (OCT).

Comparatively, the novice surgeon elicited a volume defect that significantly varied from the intermediate (P =.016) and experienced surgeon (P =.0002). In total, 12 patients received microperimetry measurements demonstrating an association between inner retinal volume defect and reduced retinal sensitivity (P =.02).

The study confirms the hypothesis that ILM peeling in areas of significant inner retinal damage is due to iatrogenic forceps grasp damage. It demonstrates that by linking the location of ILM-peeling initiation in surgical videos to anatomical inner retinal features imaged using swept-source OCT. In further support of this hypothesis, the study shows that inner retinal damage from forceps is linked to decreased retinal sensitivity at the level of ILM-peel initiation.

Based on their research findings, the investigators suggest that microscotomas are not only a repercussion of the separation of the ILM from the inner retina, but also from the forceps grasp site where deeper inner retinal trauma can span past the retinal nerve fiber layer.

“Perhaps, virtual reality training can improve patient-related outcomes in vitreoretinal surgery. Recently, virtual reality surgical training in ophthalmology has enabled novice surgeons to take their first steps in a safe and standardized learning environment with feedback loops,” the researchers recommend. This virtual reality training could permit gradual enhancement of technical skills before doing a surgery and thus facilitate better results.

A main strength of the study is the objective/validated methodology in identifying ILM-peeling initiation, as well as the capability of quantifying the amount of inner retinal volume defect. Limitations include only a few participating surgeons, as well as the retrospective design. This retrospective analysis allowed access to only preoperative data and yielded limited variations in surgical approach. 

This study focuses on only technical skill and not other nontechnical areas of expertise including adaptive, cognitive, and interpersonal skills.


Alberti M, Jacobsen MF, Hermann MN, et al. Quantifying surgical skill in macular surgery. Acta Ophthalmol. Published online September 22, 2021. doi:10.2147/OPTO.S235679