1. What surgical case do you find most enjoyable to perform and most rewarding once completed?
I do not think there is just 1 procedure that I particularly enjoy. However, I like to perform macular hole surgery very much, especially now that we often use brilliant blue dye to stain the internal limiting membrane. It is a fast procedure, and 1 that is particularly demanding because you must be delicate with your instruments and have a very clear view of the posterior pole. Macular hole surgery is also a satisfying procedure to perform because it has a success rate of more than 90-95%. If you perform this surgery at the initial stages of macular hole formation, and, consequently, the patient's visual acuity has not decreased much, the outcomes are very good, and results of 20/20 vision can be achieved.
The other procedure that I like to perform is scleral buckling. Today, the trend is toward performing primary vitrectomy for uncomplicated retinal detachments. I think scleral bucking is used less these days because it requires a perfect understanding of the mechanisms of retinal detachment. It is also necessary to master the technique in order to have good results. In addition, the final results are commonly seen the next day. If the retina is attached 24 hours after surgery, it is very probable that it will stay attached forever, without the need for secondary procedures. To me, scleral buckling is a surgical technique that can differentiate the surgeons who truly master retina surgery from those who do not possess the full range of skills.
2. What do you enjoy most about making surgical videos? What video-making tips can you offer?
I developed a passion for making videos when I was a teenager, as I was responsible for recording our family vacations. When I became a retina surgeon, I always looked to document my procedure, and, to date, have recorded all of my surgical cases on video. My first teaching video was a collaborative work done with Hugo Quiroz- Mercado, MD, who was my chief for more than 20 years. We presented a video at the American Academy of Ophthalmology meeting in New Orleans many years ago. After that, I wanted to create my own surgical videos. After a few attempts, I started winning awards at the video festival of the American Society of Retina Specialists. Today, I have a total of 5 of these awards, of which I am very proud.
Do I have advice on how to create a nice video? Quality video making requires creativity and innovation, and you must be able to make the videos by yourself using several types of software. I love Mac software and use Final Cut (Apple) for my videos. Think about the audience, and it will come along. And always try to have fun!
3. Have any recent studies or new technologies influenced your surgical technique?
Years ago, Didier Ducournau, MD, a good friend of mine, explained to me the benefits of the peristaltic pump in vitreous surgery. Being a surgeon with no financial interest in any surgical company, I can feel free to give unbiased opinions about the new technological advances in vitrectomy machines. After trying many vitrectomy machines with peristaltic pumps, I realized that this technology is truly the best. The control in fluidics is better than that with venturi pumps. Please be advised that I am not an engineer; I am a regular surgeon who can recognize differences in various platforms. That is why I can say that if you want the best control in vitrectomy, you need to look into a peristaltic pump. This does not at all mean that venturi systems are bad. The duty cycle of the venturi pump is good, but, in my experience, it does not surpass the peristaltic pump.
4. As a surgeon, who are your heroes?
This is an interesting question. As a surgeon, I think it is mandatory to have teachers and leaders who influence your ideas and concepts in surgery. To me, the greatest heroes are those who solved key issues, created solutions, and built the technology that formed modern vitreoretinal surgery.
My father is a retired glaucoma specialist who was trained by Robert Shafer, MD, in San Francisco. There is no question that when he returned to Mexico, he was considered the father of glaucoma in our country. So, without a doubt, my father is my biggest hero. He taught me many key things in surgery. He did not give me advice in retina surgery, but I have extrapolated many surgical tips that I can apply to my practice. I remember he always said when he was performing surgical iridectomy that, “The key point is that you perform the surgery in such a way that the eye will not notice.” I use this approach in many of my procedures, which is why I always look for the best ways to perform fast and effective surgery. This does not mean “incomplete,” but rather that all surgical steps are optimized in order to perform a complete surgery as quickly as possible.
Specifically in the field of retina, I was lucky to befriend Yasuo Tano, MD. He visited the Hospital Asociación para Evitar la Ceguera in Mexico City several times, and I had the opportunity to discuss and be involved in several surgical cases with him. He was an absolute master in surgery. Also, several years ago, I was an invited surgeon of Cesare Forlini, MD, in Pesaro, Italy. There, I saw him perform “total eye surgery,” from perfect corneal grafts to cataract surgery to precise retinal surgery. After seeing that, I learned that Cesare has very skilled hands. He is also 1 of my heroes.
After heroes such as Jules Gonin, MD; Ernst Custodis, MD; Robert Machemer, MD; Conor O'Malley, MD; Charles Schepens, MD (with whom I had the pleasure of, in some way, training as part of his group); Stanley Chang, MD, and many more, there is a very close friend of mine, Dr. Quiroz- Mercado, who is the son of a great ophthalmologist who taught my father. From him, I learned several things about surgery, such as how to be calm, how to stay relaxed even when the OR is a complete disaster, and many other philosophical aspects applicable not only to surgery but also to real life. My future heroes might be the fellows of our retina department. They are always creative, and I learn many good tips from them. I believe that you start learning from your heroes, and, throughout the years, end up learning from your students. The nice thing is that you never stop learning!
5. What, in your opinion, makes being a retina surgeon in Mexico unique as compared with the United States?
In Mexico, we are very fortunate to have a geographical situation with some benefits. Our largest neighbor is the United States, which is why our medical knowledge is so comprehensive. Federal regulations are very strict in Mexico, but we are fortunate to have a slightly more open field of research than in the United States. This enables us to use many surgical platforms that are not allowed in the United States and to try surgical compounds that are not approved there, such as brilliant blue, which has been demonstrated by many researchers to be safe. We are fortunate to practice in a country that medically is not considered a developing country, but our regulations are less strict and therefore allow us to do a little more.