EYES WIDE OPEN With technology evolving rapidly, retinal surgeons have to have the discipline to keep learning every day.

There's a revolution underway in retinal surgery. In a very short period of time, a 20-gauge surgery that required sutures and often general anesthesia has become a 25- or 27-gauge surgery that's suture-less and usually done under local anesthesia. Our new techniques are far superior. We've improved efficiency, we've improved safety and we've improved outcomes. And these huge leaps forward are just the beginning. The field is going to be advancing even faster over the next few years. To take full advantage of the rapid pace of improvement, you'll need to understand these 4 key components of a successful vitreo-retinal surgical practice.

1 Have the right surgeons with the right attitude. The surgeons you choose are ultimately going to determine the success or failure of the center. Technical skill isn't enough. There are some very good surgeons who still haven't adapted and adopted new techniques. Retinal surgeons have to be completely open-minded and have the discipline to learn new things every day. That flexibility requires energy, discipline and a willingness to step away from complacency.

There's no denying that speed is an important component of profitability. But with surgeons, it's essential to understand and stress the difference between speed and efficiency. What's most important is having the commitment to provide the best possible care for your patients. Patient care must always be No. 1 and profitability always No. 2. As long as you have those priorities set properly, you'll be on the right track.

2 Take advantage of increasingly precise instruments and better visualization. With small-incision vitreo-retinal surgery, we can use techniques that produce far less trauma and far better outcomes. We have 23- and 25 gauge instruments, and soon we'll have 27-gauge (the 27+ Portfolio, recently introduced by Alcon). Since I prefer to use the smallest gauge available, when the 27+ becomes available, I'll use that for all of my cases. The smaller the wound, the better.

The smaller gauges also provide a smaller sphere of influence, which reduces collateral damage, and increases the precision of your dissection. With a 20-gauge instrument, it can be like using a vacuum cleaner to pick up one M&M from a bowl that contains dozens — normal retina tissue is incarcerated with fibrous tissue. The smaller gauge is like a small straw that lets you pick up one M&M without disturbing the others. You can remove tissue in a much more precise manner. There's a certain amount of skill and adaptability involved, but nothing that can't be mastered by a good vitreo-retinal surgeon.

Improved visualization is an enormously important area that will likely become even more important over time. One of the biggest advances is wide-field visualization. We can see a lot more peripheral tissue and do a lot more peripheral dissection. I now do all of my cases using 3D glasses and a flat-screen display with 3D images: heads-up 3D surgery. I get a digitalized picture I can manipulate in any number of ways. As the technology advances, we're also on the precipice of having multimodal heads-up visualization, so we won't have to look into a microscope.

3 Understand and manage costs. It's easy to see the start-up costs with retina as daunting. You need lasers, you need cryotherapy, you need a vitrectomy machine, you need gas, you need instruments and so forth. Even if you're already doing cataract surgery, the equipment needed for vitrectomy is entirely different. To equip an OR for retina, the cost is at minimum $500,000.

It's definitely significant, but in a well-run facility, the overall overhead for equipment and disposables — which I've calculated now for many years — should turn out to be less than 20% of the total overhead. The No. 1 expense? Personnel. It's vitally important that everyone on the staff is used in the appropriate place — that you have skilled staff doing skilled work, not simple tasks. For instance, you don't want to have an RN turning a knob on a laser at your verbal command when you can control it with a foot pedal. When you understand that staff is the more significant cost factor, you also realize there's no good reason to skimp on equipment. Most importantly, there is absolutely no reason to cut corners on providing the best patient care possible.

PERSONNEL DISCIPLINE Since staff is the most significant expense, skilled personnel should be doing skilled work only.

4 Educate patients and don't limit your caseload. The most challenging cases are patients who have complications from diabetes. The abnormal blood vessels that form as a result of diabetes often bleed and scar, and the scar tissue then pulls on the retina, causing it to tear and detach — what's called a combined traction rhegmatogenous retinal detachment. But patients need to understand that they're better off having this delicate surgery in a highly specialized center that has the best equipment and the best staff. They're better off dealing with people who know this disease as specialists at every level, from the physician to the nurses to the technicians to the front desk staff. In short, where the care provided is simply better.