Sandra Hoyek, MD and Melissa Yuan, MD
Mass Eye and Ear, Boston MA
The Surgical Retina Debates session at VBS 2025, moderated by Drs. Virgilio Morales Canton and Adrienne Scott, brought a lively series of debates on surgical innovations and preferences, showcasing expert perspectives. From the choice of vitrectomy platforms to the best method for melanoma biopsy,—and the controversial question of office-based vitrectomy,—these sessions offered valuable insights for surgeons navigating evolving technologies and clinical paradigms.
The session kicked off with a spirited discussion on vitrectomy platforms, where three seasoned surgeons made the case for their preferred systems. Dr. Katherine Talcott advocated for Alcon, highlighting the company’s advanced fluidics and precision cutting capabilities. Dr. Ajay Kuriyan presented the strengths of Bausch + Lomb, emphasizing its surgeon-driven design and efficiency. Dr. Colin McCannel rounded out the debate with a case for DORC / Dutch Ophthalmic USA, focusing on its flexibility and surgeon-controlled vacuum settings. A lively discussion followed, with audience members weighing in on their experiences with each platform. During the discussion, all of the participants agreed that fellows should ideally be exposed to multiple platforms during training.
The audience asked thoughtful questions about costs of startup and how challenging it is to switch between various platforms, and Dr. Talcott reminded the audience that the support staff and reps for all of the machines are excellent. Dr. Morales reminded the audience that the most important thing is “to know the machine”, and Dr. Scott recommended that fellows show up early and learn from the scrub tech setting up the machine. Ultimately, DORC came out with 48% of the audience’s votes, followed by Alcon with 42%, and B&L with 11%. While no clear “winner” emerged, the session underscored how personal preference, surgical technique, and case complexity often dictate platform selection.
Next, the theme shifted to intraocular melanoma biopsy techniques, where two ocular oncologists presented their preferred approaches. Dr. Kisha Piggot championed needle-assisted melanoma biopsy (FNAB), citing its minimally invasive nature and lower risk of tumor seeding. In contrast, Dr. Tara McCannel made the case for cutter-assisted melanoma biopsy, highlighting its efficiency in obtaining larger, more reliable tissue samples for genetic analysis. Dr. McCannel also emphasized that the cutter is what sets retina-trained ocular oncologists apart, and that this should be used to our advantage. The discussion that followed delved into real-world applications, including when each technique may be preferable based on tumor size, location, and the need for molecular prognostication. Impressively, the audience vote was an exact 50/50 split!
Perhaps the most provocative discussion of the session centered on the feasibility of office-based vitrectomy. With increasing interest in office-based surgical centers (OBSC), some argue that retina should follow the path of anterior segment surgeons, while others remain skeptical due to concerns about safety, reimbursement, and logistical challenges. Dr. Omar R. Shakir strongly advocated for office-based vitrectomy as the future of vitreoretinal surgery, presenting his experience with over 1800 cases, including 600 consecutive vitrectomies, as evidence that this approach is not experimental but an efficient and proven alternative to ambulatory surgical centers and hospitals. He emphasized that office-based surgery allows for immediate intervention in urgent cases, reducing delays that often occur in ambulatory surgical centers (ASCs) and hospitals. He also pointed out that eliminating the need for an anesthesiologist by using peribulbar and subconjunctival blocks not only reduces systemic risks associated with general anesthesia but also lowers costs significantly. Without hospital facility fees, surgeons have greater control over their equipment and surgical workflow, making office-based vitrectomy a cost-effective and surgeon-driven model. He concluded with a call to action, urging retina surgeons to embrace this shift rather than lag behind their anterior segment colleagues, arguing that office based surgery not only empowers surgeons but also enhances patient care.
Taking the opposing stance, Dr. Alia Durrani outlined the significant challenges that make office-based vitrectomy impractical and potentially unsafe for many retina patients. She emphasized that the patient population undergoing retina surgery is vastly different from those receiving cataract or refractive procedures in that many retina patients are elderly and medically complex, often managing cardiovascular disease and other systemic conditions that increase surgical risks. Without the infrastructure of a hospital or ASC, managing complications could become challenging, particularly in the absence of on-site anesthesia providers and emergency preparedness measures. Furthermore, she raised concerns about the financial feasibility of office-based retina surgery. Unlike cataract procedures, which have seen a push for office-based models, the Centers for Medicare & Medicaid Services (CMS) has not approved facility payments for office-based retina surgeries, making it difficult for surgeons to sustain an OBSC without incurring significant costs. Additionally, moderate sedation fees are not reimbursed in office settings, further increasing financial barriers. Beyond logistical and financial concerns, Dr. Durrani cautioned that moving vitrectomies out of ASCs and hospitals could have unintended consequences on retina training programs. Complex procedures, such as scleral buckling, membrane peeling, and trauma repairs, require a structured training environment to ensure the next generation of retina surgeons develops the necessary skills. She argued that shifting these procedures to office-based settings could limit access to these critical learning opportunities, potentially compromising surgical education. While acknowledging that office-based surgery may be appropriate in select cases, she emphasized that it is far from a universally viable model for retina surgery. Until there is more robust safety data and proper reimbursement structures in place, she urged caution in widely adopting this approach. While office-based procedures have gained traction in some areas of ophthalmology, the debate underscored the many hurdles still facing widespread adoption in retina. The audience vote favored Dr. Durrani’s argument with 75% vs 25% voting for in-office vitrectomy.
Overall, these engaging debates provided a glimpse into the evolving landscape of vitreoretinal surgery, where technological advances continue to shape surgical decision-making. Whether refining platform preferences, optimizing biopsy techniques, or exploring the future of office-based surgery, these discussions are vital in pushing the field forward.
