By John W. Kitchens, MD
This study published in Retina in January examines the relationship between surgeon experience and success rates in retinal detachment surgery. The results indicate that experience does influence the outcome of this surgery but mainly at the beginning of training. The authors also conclude that highly experienced surgeons are not necessarily the most successful. They say that the learning curve is the sensitive period during which success is mostly modified and improved, which supports the importance of extensive training of young surgeons by experienced supervisors.
This paper has drawn great interest from training programs. It sets out to answer a question to which we all seem to inherently know the answer. It concludes that while surgical experience does have a role in the success of retinal detachment surgery, this relationship is tough to quantify, akin to trying to solve a math equation with words. Interestingly, this paper comes from a fellowship training program in Germany which may highlight some of the differences in training styles and surgical choices.
The authors correlated the total number of vitreoretinal procedures performed by each of eight surgeons to their individual success rates during 11 months of follow-up of a combined 375 scleral buckling or vitrectomy retinal detachment procedures completed during a five-year period. The study focused on uncomplicated primary procedures.
Mean primary anatomical success rates were 0.69 ± 0.14 for scleral buckling and 0.9 ± 0.05 for primary vitrectomy (P < 0.05). These rates did not correlate to the number of vitreoretinal procedures performed by each physician. The failure rate of scleral buckling was quite high, at 69 percent, compared with 90 percent for primary vitrectomy.
Seven surgeons showed an intra-individual learning effect, with better success rates in the second half of the observed procedures. The learning effect was higher in inexperienced surgeons but was reduced by half after 500 vitreoretinal procedures. There was also no significant difference in the learning effect for vitrectomies versus scleral buckling.
The paper was highlighted by the editors of Retina, with an editorial response written by Andrew M. Schimel, MD, M. Gilbert Grand, MD, and Harry W. Flynn, Jr, MD. They astutely point out the reduced success rate of scleral buckling in this paper, noting that, "A large review of recent Medicare data demonstrated higher rates of recurrent retinal detachment surgery in patients who underwent initial pars plana vitrectomy (21.2%) than those who underwent initial primary scleral buckle procedures (19.2%, P = 0.044). Furthermore, individuals receiving initial pars plana vitrectomy +/- scleral buckle were two times more likely to suffer adverse outcomes than were those undergoing scleral buckle alone."
The study's authors say their results clearly demonstrate that differences in the outcome of retinal detachment surgery are more complex than simply assuming that surgical experience is the most important factor for success.