Office vitrectomy: A full-scale replacement for the ASC and hospital

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As I sat down to gather my thoughts on the transformative power of office-based vitrectomy, my initial aim was a nuanced comparison with its counterparts—the hospital and the ambulatory surgery center (ASC). The more I thought about it, the more fervent my conviction was that office-based surgery is the future. I cannot dilute this argument by positioning office vitrectomy as a viable alternative: After having performed 450 sequential vitrectomies in the office, it is simply the better alternative. A paradigm shift is underway.

We stand on the cusp of a new era in vitreoretinal surgery, one that has been marked by only a select few seminal innovations. These include vitrectomy itself and high-speed cutting technology, advanced tamponade agents, assistant-free widefield viewing systems, intraoperative optical coherence tomography, digital microscopic visualization, and vital dye staining. Now we are poised to embrace a novel concept that promises to catalyze future advancements: full-scale comprehensive office-based vitrectomy. This has the power to be the breeding ground for all future innovation in vitreoretinal surgery.

Elevating patient-centric care

The integration of office-based retinal surgery into my practice has not only revolutionized my approach but also substantially elevated patient care. With the convenience of a well-equipped, top-notch surgical suite, I can offer (and I routinely do) immediate vitrectomy for the time-critical conditions of retinal detachment, endophthalmitis, and intraocular foreign body. Each of these conditions has benefited from same-hour diagnosis to treatment.

This immediacy extends to a plethora of conditions, including macular holes, vitreous hemorrhage, diabetic vitrectomies, dislocated IOLs, and retained cataract nuclear fragments in the vitreous, among others. The expedited treatment pathway is appreciated by patients who, understandably, prefer to have their vision restored without delay. This quick solution is how I would want to be taken care of.

Our center places immense value on creating a serene and comforting environment to alleviate preoperative anxiety. Thorough surgical counseling with attention to the emotional journey, swift scheduling, modern facilities, and bespoke preoperative care set the tone for a tranquil experience. Our patients are greeted with a familiar and friendly staff in a setting devoid of the typical preoperative bay alarm bells, intravenous placements, buzzing nurses, an anesthesia provider they have never met, and all the anxiety-provoking elements of a new experience. They are instead welcomed with amenities such as leather massaging recliners, fresh pastries, hot coffee, and a relaxing visual ambiance, contributing to a significantly more pleasant health care journey.

Surgeon autonomy and flexibility

I have encountered many situations even in my young surgical career where I requested certain products or equipment and was met with resistance. More often than not, there was no such thing as an alternative option. Operating within an office-based setting has afforded me
unprecedented autonomy over the surgical environment. The freedom to select cutting-edge technology and instruments without the constraint of external approvals has markedly enhanced the quality of care I provide.

For example, I wanted to use TissueBlue instead of indocyanine green, or I wanted to trial a higher cut rate machine or try a different style cutter, or I wanted the CT Lucia 602 lens for scleral fixation and not the Alcon MA60, and the list goes on. In an office-based setting, the surgeon is in total control, as they should be.

Scheduling flexibility is yet another benefit that aligns with both patient convenience and surgeon work-life balance. The constraints of “adding on” cases to a full ASC or hospital schedules are a relic of the past. Office-based surgery affords me the liberty to operate within standard clinic hours, barring emergencies, thereby streamlining my professional practice. In the 3 years I have been performing office vitrectomy, night and weekend cases have been rare and by my choice, not the choice of operating room (OR) administrators.

Surgeon control is good for everyone. The physician ideally determines the technology they believe in most and the best treatment plan. In an office-based setting, you get to do exactly that. For example, I would have never gained access to digital microscope visualization in my previous surgery center because it would never be considered by the capital budgeting committee. I saw value in it, so I presented it to my committee of 1 (myself). The less red tape you require yourself to run into, the more efficiently you can perform your life-changing work.

The healthcare system benefits

The move toward office surgery is an imperative shift in response to the escalating costs of health care. As health care professionals and dutiful citizens, we have dual responsibility as stewards of societal resources. It is incumbent upon us to pioneer efficient, safe, and cost-effective surgical solutions.

By simplifying the surgical milieu and cutting out waste, we can minimize the demand on valuable health care resources, such as anesthesia and nursing, that are vital elsewhere. An office setting naturally aligns with a lean approach, requiring just a scrubbed assistant and a circulator, thereby mitigating the burden on the broader health care workforce. The way we currently perform surgery is too resource intensive on all fronts—staffing, footprint, time, consumables, and so on.

Going green

Reducing waste and our carbon footprint must be top of mind in any innovative solution going forward. Our facility generates less waste than a typical OR and embraces the principles of just-in-time (JIT) inventory management to minimize additional waste.

The JIT method is important to reduce overstocking, obsolescence, excess packing and cardboard breakdown, transportation, refrigeration, footprint, and so many other impactful inefficiencies. Traditional operating facility leadership tend to work against these principles with administrators who contribute to bloat and anti-lean practices. Surgical back table packs are customized to reduce unneeded items.

Utilization of gloves, prep materials, sterile supplies, and other consumables is significantly reduced compared with every surgical setting I have seen. Typical waste generation from a busy surgical day (15 cases) may fill three 40-gal trash bags at most. Our energy consumption is optimized, negating the need for the extensive and power-intensive infrastructure of conventional ORs. We do not require excessive cooling, negative pressurization, laminar air flow, and other energy-intensive features of a typical OR.

Accreditation and safety

Our commitment to excellence in this new surgical setting is underscored by our accreditation through the Joint Commission. The Joint Commission recognition is a testament to our adherence to the highest health care standards. We opted for an ophthalmic-specific accreditation pathway to ensure our practices are benchmarked and specialized to the unique demands of ophthalmic surgery.

All the accrediting organizations in the office-based surgery environment are the same ones that evaluate ASCs; however, the specific accreditation we chose for our center was the most rigorous of the options. Office-based surgery has had a separate program within the Joint Commission since 2001, and now together with iOR Partners, there is a partnership for setting standards strictly for ophthalmic office-based surgery.

In summary, office-based vitrectomy is more than an emerging trend—it is a definitive step forward in the field of vitreoretinal surgery. It represents a symbiosis of elevated patient care, innovation, surgeon empowerment, sustainability, and so much more. It is poised to become the foundation for current surgical care and future breakthroughs in the specialty.

Omar Shakir, MD

Omar R. Shakir, MD, MBA

Shakir is the CEO of Coastal Eye & Coastal Eye Surgery Center in Greenwich, Connecticut. He is an instructor at Yale University and a consultant for Bausch + Lomb, Zeiss Meditec, Beyeonics, iOR Partners, and Topcon Medical.