OSLI Retina

May 2020

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256 Ophthalmic Surgery, Lasers & Imaging Retina | Healio.com/OSLIRetina Practical Retina Incorporating current trials and technology into clinical practice Evolution of Primary Scleral Buckling Surgery: A Modified Lean Six Sigma Technique to Improve Surgical Efficiency by Thomas A. Ciulla, MD, MBA; Rehan M. Hussain, MD; and Justin H. Townsend, MD There is no uncertainty that advanc- es in vitrectomy surgical techniques have decreased the number of scleral buckles used to repair retinal de- tachments. The annual American Society of Retina Specialists Prefer- ences and Trends Survey has shown declining num- bers of scleral buckles used year over year. Un- less scleral buckle techniques evolve, to help us keep up with external pressures such as ambulatory surgery center surgical times, this procedure may become a lost art. I have asked Thomas A. Ciulla, MD, MBA, Rehan M. Hussain, MD, and Justin H. Townsend, MD, to dis- cuss their interesting experience us- ing Lean Six Sigma methodology to increase efficiency of scleral buck- ling surgery. They will discuss mod- ern-day challenges that currently tip the scale against scleral buckle use and propose solutions based on each step of this procedure. Their advice, if implemented, may reduce waste and potentially provide cost savings while maintaining favorable patient outcomes. I am certain that their insights will be very valuable for maximizing surgical outcomes in patients with retinal detachments — but enabling us to do so while respecting external challenges surrounding modern-day vitreoretinal surgery. INTRODUCTION Pars plana vitrectomy (PPV) surgery has advanced tremen- dously in the past two decades, facilitating the migration of vit- reoretinal surgery from the hospital operating room (OR) to the ambulatory surgery center (ASC); however, innovation in scleral buckling (SB) surgery has lagged behind. This has created a di- chotomous paradigm with technologically advanced PPV sur- gery and decreasing surgical times, in contrast to technologically stagnant SB surgery and static surgical times. Consequently, it is not surprising that a recent retrospective cohort study of 31,995 eyes with primary rhegmatogenous retinal detachment (RRD) re- pair from 2003 to 2016 revealed that PPV has progressively be- come the most commonly used procedure, whereas SB utiliza- tion has declined. 1 According to the 2019 ASRS Preferences and Trends Survey, when asked their surgical approach to a phakic superior RRD with a single tear, only 23% of United States ret- ina specialists chose primary SB, whereas 33% chose primary PPV, 7% chose combined SB/PPV, and 36% chose pneumatic retinopexy. 2 Soon, SB surgery could become a lost art, narrow- ing surgical options for patients, unless SB techniques advance with improved surgical times in ASCs while also retaining good outcomes and patient satisfaction. Thomas A. Ciulla Rehan M. Hussain Justin H. Townsend doi: 10.3928/23258160-20200501-02 Seenu M. Hariprasad Practical Retina Co-Editor

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