Introduction

Since Schepens introduced scleral buckle surgery for retinal detachment in 1951,¹ and Machemer developed vitrectomy in 1971,² the vitreoretinal subspecialty has undergone significant advancements over the past few decades. The introduction of sutureless small-gauge transconjunctival microincision vitrectomy surgery (MIVS) in 2002 revolutionized vitreoretinal procedures by improving surgical precision, minimizing intraoperative complications, and substantially reducing postoperative recovery times.³ Concurrently, advanced vitreous-retinal interface imaging systems, such as optical coherence tomography (OCT) introduced in 2004,⁴ transformed the diagnostic and therapeutic landscape by enabling unparalleled visualization of retinal structures and facilitating more precise surgical interventions. These innovations have influenced clinical practice by improving success rates of vitreoretinal surgery and contributing to the expansion of vitreoretinal surgeries while more and more vitreoretinal disease can be detectable and treatable.

Previous studies have reported increasing trends in vitreoretinal surgeries across developed countries, including the United States (2010~2012),⁵ the United Kingdom (1968~2004),⁶ Australia (2001~2019),⁷ Korea (2002~0213)⁸ and Japan (2010~2017).⁹ These findings reflect real-world clinical practices, enabling health planners to allocate medical resources more efficiently and improve the quality of healthcare. However, the data from these studies may be considered relatively outdated, and might not accurately represent current clinical practices or disease prevalence. Moreover, there is a notable lack of comprehensive data on vitreoretinal surgery trends in developing countries, particularly China. This lack of up-to date, region-specific data highlights the urgent need for research to better understand and address the evolving demands of vitreoretinal services in China.

This study aims to analyze trends in vitreoretinal surgeries at a tertiary ophthalmic center in China and project surgical volumes for the next decade. Accurate surgical trend predictions are essential for justifying increased funding for retinal surgery departments and guiding workforce planning, including surgeon recruitment and training. Additionally, this study aims to offer critical insights into the future structure of vitreoretinal services in China, supporting the development of more efficient healthcare policies for patients.

Materials and Methods

We conducted a single-institution, retrospective database analysis of patients hospitalized in the retinal surgery department, utilizing the inpatient database of Zhongshan Ophthalmic Center (ZOC), Sun Yat-sen University, a leading tertiary specialized hospital in China. The analysis utilized inpatient database records spanning January, 2005 to December, 2022, specifically focusing on patients undergoing vitreoretinal surgical surgeries. In China, vitreoretinal surgeries, including PPV and scleral buckle surgeries, are predominantly performed as inpatient procedures due to clinical management practices and healthcare policies. Minor procedures, such as intravitreal injections, are typically conducted on an outpatient basis and were therefore excluded from this study.

This study obtained ethical approval from the Research Ethics Committee of ZOC (Number: 2023KYPJ021) before conducting the study. Informed consent was waived by the Research Ethics Committee of ZOC because of the retrospective nature of our study. Patient data were anonymized and handled in accordance with institutional guidelines on confidentiality and data protection. Patients who received intravitreal injections were excluded, as these procedures are outpatient rather than inpatient surgeries.

Patients were classified based on their final diagnoses into the following groups: rhegmatogenous retinal detachment (RRD), other retinal detachment (other RD), diabetic retinopathy (DR), macular diseases (MD), vitreous hemorrhage (VH), lens problems and other retinal diseases. The macular diseases group was further stratified into 7 subgroups, including macular hole (MH), epiretinal membrane (ERM), macular degeneration, macular hemorrhage, vitreous-macular traction (VMT), macular schisis and other macular diseases.

Diagnoses were recorded using both ICD-10 codes and Mandarin text to ensure accurate identification of the main diagnosis. Data management and statistical analyses were conducted using Microsoft Excel 2019 (Microsoft Corporation, Redmond, WA, USA), and figures were created using GraphPad Prism version 9.0.0 (GraphPad Software, Boston, Massachusetts USA), with bar or line graphs illustrating the findings. Descriptive statistics (mean ± standard deviation) were used to summarize the age for each diagnosis.

A predictive analysis was conducted to estimate the monthly number of vitreoretinal surgeries through the end of 2032. This analysis utilized the open-source Prophet package, an additive regression model that leverages historical surgical data to predict future trends.¹⁰ For this model, historical monthly data from 2005 to 2022 were input into the model, which provided a forecast of monthly vitreoretinal surgeries from January 2023 to December 2032, with 95% confidence intervals (CI). The model automatically identified and adjusted for outliers, assigning substantial negative weights to data points corresponding to the COVID-19 lockdown periods in China (February, 2020 to April, 2020 and November, 2022 to January, 2023), given that such anomalies are unlikely to recur in the future.

Results

From 2005 to 2022, a total of 68,212 vitreoretinal surgeries were performed and included in this study. Table 1 provides an overview of the basic demographic and clinical characteristics of patients who underwent vitreoretinal interventions. The average age of patients undergoing surgery was 49.30 (16.44) years, with MD having the highest average age at 59.02 (11.62) years. Males exhibited higher incidence rates for RRD, other RD, DR, VH, lens problems and other retinal diseases. In contrast, macular diseases were more prevalent among female patients. Seventy-one percent of patients are originated from Guangdong province.

Table 1 Demographic Information of Patient Hospitalized in Retinal Surgery Department in the Guangzhou, 2005~2022

The inpatient numbers and rate for each disease category from 2005 to 2022 are illustrated in Table 2, Figure 1A and B. The total number of surgeries increased sharply, rising from 1,456 cases in 2005 to 5,600 cases in 2022. RRD was the most common indication for vitreoretinal intervention. Although the consistent growth in the number of RRD patients over the years, the proportion declined steadily. Notably, the MD category experienced a significant rise after 2010, increasing form 273 cases (10.45%) in 2010 to 1,197 cases (21.38%) in 2022. Similarly, DR cases doubled in the first decade, rising from 7.21% in 2005 to 13.64% in 2014, and then continued to increase steadily. Additionally, the rate of lens problems increased steadily over the years, although the number of cases remained relatively low compared to other categories.

Table 2 2005–2022 Actual Number of Vitreoretinal Surgeries

Figure 1 Number and rates of each vitreoretinal disease underwent vitreoretinal surgeries. (A) The total amount of vitreoretinal surgeries each year is increasing over the years. (B) RRD is the most common cause of patients underwent vitreoretinal surgery, followed by DR and MD, which has an increasing trend over the past few years. Abbreviations: RRD, rhegmatogenous retinal detachment; DR, diabetic retinopathy; MD, macular diseases; VH, vitreous hemorrhage; RD, retinal detachment; MH, macular hole; ERM, epiretinal membrane; VMT, vitreal macular traction.

Figure 2A and B show the inpatient numbers and rates of each macular disease subgroup. The data indicate that MH was initially the predominant subgroup; however, ERM surpassed MH in 2021. Additionally, the numbers and rates of VMT and macular schisis increased steadily over the years.

Figure 2 Number and rates of each macular disease subgroup. (A) The total amount of MD each year is increasing over the years. MH and ERM are the main two subgroups in MD. (B) MH and ERM are the main two subgroups in MD over the years. Abbreviations: RRD, rhegmatogenous retinal detachment; DR, diabetic retinopathy; MD, macular diseases; VH, vitreous hemorrhage; RD, retinal detachment; MH, macular hole; ERM, epiretinal membrane; VMT, vitreal macular traction.

Figure 3 illustrates the projected number of vitreoretinal surgeries. The predictive analysis estimated that, based on current trends, the total number of vitreoretinal surgeries (Figure 3A and Table 3), DR (Figure 3B and Table 4), MD (Figure 3C and Table 5) and lens problems (Figure 3D and Table 6) will incrementally increase annually, but with a declining growth factor. At the current trajectory, the total number of vitreoretinal surgeries projected for 2032 is approximately 9,231 (95% CI: 8746–9717), with DR, MD and lens problems are estimated to account for 1,730 (95% CI: 1635–1828), 1,959 (95% CI: 1860–2065), 489 (95% CI: 447–532) surgeries respectively.

Table 3 Predicted Number of Vitreoretinal Surgeries from 2023~2032

Table 4 Predicted Number of DR from 2023~2032

Table 5 Predicted Number of MD from 2023~2032

Table 6 Predicted Number of Lens Problems from 2023~2032

Figure 3 Predictive future trend. (A) vitreoretinal surgery. (B) DR. (C) MD. (D) lens problems. Actual numbers of surgeries from 2005 to the end of 2022 (light blue). Forecasted numbers of monthly surgeries for a 10-year period from 2023 to the end of 2032 (navy blue) with 95% confidence intervals (grey shaded area). Abbreviations: DR, diabetic retinopathy; MD, macular diseases.

Discussion

This study retrospectively analyzed over 60,000 patients from the ZOC inpatient database spanning 2005 to 2022, focusing on those hospitalized in the retinal surgery department. The analysis revealed a significant upward trend in vitreoretinal surgeries, with the total number of procedures increasing nearly fourfold. Predictive analysis indicating increasing trends in total vitreoretinal surgeries, as well as DR, MD, and lens problems. These finding offer workforce planners and healthcare policymakers valuable insights into future landscape of the vitreoretinal field in China, influencing clinical practice.

The total number of vitreoretinal surgeries experienced a steep rise from 1,456 cases in 2005 to 5,600 cases in 2022, particularly within the macular diseases category. However, a notable decline was observed in 2020 and 2022 due to the outbreak of the COVID-19 pandemic and subsequent lockdowns. Several factors contribute to the observed overall increase in vitreoretinal surgeries. Retinal diseases such as RRD, MH, and ERM typically peak in prevalence among individuals in their 50s,^11–13 reflecting their higher incidence in an aging population. An aging population and a rising number of cataract surgeries have contributed to an increase in complications, such as ectopic lens and ectopic IOL, requiring further vitreoretinal interventions. As China transitions into an aging society,¹⁴ the demand for vitreoretinal surgeries has increased.

Another significant factor driving the increase in vitreoretinal surgeries, particularly vitreomacular interface disorders such as ERM and VMT, is the widespread adoption of OCT. OCT uses infrared light to capture in vivo retinal images, offering non-invasive, high-resolution cross-sectional views. This technology has revolutionized the way how ophthalmologist assess and manage vitreoretinal interface diseases by enabling detailed visualization of retinal structures, especially factors critical to surgical outcomes. The advanced imaging capabilities of OCT have facilitated ophthalmologist in early detection, precise diagnosis, and effective monitoring of disease progression, thereby significantly improving clinical outcomes in vitreoretinal surgery.

The advent of vitrectomy, particularly the development of 25G and 27G pars plana vitrectomy (PPV), has also played a pivotal role in making a greater range of retinal diseases become treatable The improvement of surgical technologies has allowed for smaller incisions and shorter operative time, substantially reduces surgical trauma and accelerating postoperative recovery. These advancements have made vitreoretinal surgery less invasive and more efficient, resulting in shorter postoperative recovery times and fewer complications.^3,15,16 These benefits have improved success rates and patient satisfaction, encouraging more patients to opt for vitreoretinal surgery.

The prevalence of DR in this study rose significantly, which can be attributed to several factors. China has the largest diabetic population globally, and this population is estimated to increase in the future.¹⁷ The anticipated increase in China’s diabetic population is expected to significantly elevate DR prevalence. Although there are several approaches, such as intravitreal anti-VEGF and laser photocoagulation, to prevent non-proliferative diabetic retinopathy (NPDR) from progressing into proliferative diabetic retinopathy (PDR) effectively nowadays,^18,19 there has been nearly a threefold increase in the rate of PPV for PDR, from 7.21% in 2005 to 19.2% in 2022. However, previous studies conducted worldwide, including in the UK, the US, Australia, and Japan, have shown differing results, likely due to the widespread use of anti-VEGF therapy and well-developed medical management of the disease in resource rich countries.^5,7,9,20 This disparity highlights the critical need for annual diabetic screenings to enable early detection and timely treatment of DR. Collaborative efforts between ophthalmologists and endocrinologists are essential to improve diabetes management. Additionally, these findings should encourage government authorities to prioritize DR management and strengthen public health strategies to address this growing concern.

The number of RRD patients continues to increase annually, and continues to play a dominant role in the retinal surgery department. The growing prevalence of myopia and pseudophakia in China, both known risk factors for RRD, is expected to drive a future increase in RRD incidence. Recent studies indicate that timely retinal reattachment within 72 hours leads to better visual outcomes, whether for macular-on or macular-off RD.²¹ This underscores the importance of training ophthalmologists in vitreoretinal departments to gain experience in diagnosing and managing RRD, as early diagnosis and intervention of RRD are critical for optimal visual outcomes. The increasing volume of non-RRD vitreoretinal surgeries has led to a relative decline in the proportion of surgeries specifically for RRD. This shift reflects advancements in diagnostic technologies and surgical techniques, along with the rising prevalence of other retinal conditions, highlighting the importance of adaptive healthcare planning and efficient resource allocation.

Our predictive analysis, based on comprehensive historical data, provides valuable insights into future trends. With China’s aging population, the prevalence of retinal diseases is anticipated to increase. According to our predictive analysis, the total number of vitreoretinal surgeries, DR, MD and lens problems will incrementally increase annually, but with a declining growth factor, likely reflecting stabilization due to saturation of service capacity, enhanced preventive care, and potential improvements in outpatient surgical management reducing inpatient necessity. Notably, our forecast model effectively identifies and adjusts for anomalies, such as the temporary reduction in vitreoretinal surgeries at ZOC during the outbreak of COVID-19 pandemic and lockdown periods (February to April 2020 and November 2022 to January 2023). This robust model minimizes the influence of these outliers, enhancing the accuracy of our long-term predictions. The future trajectory of retinal disease prevalence and treatment will be shaped by various factors, including advancements in therapies, treatment protocols, and disease prevalence. Increased public awareness of vitreoretinal diseases and the integration of OCT into primary eye care are expected to improve the detection rates for conditions requiring referral and subsequent treatment in specialized centers.

This study provides an overview of vitreoretinal surgery trend in China’s tertiary specialized hospitals, emphasizing implications for workforce planning and surgical training. Additionally, the findings offer healthcare planners insights for optimizing the structure of vitreoretinal services, ensuring efficient resource allocation, securing funding, and improving healthcare quality. However, this study had several limitations. First, the data are limited to tertiary specialized hospitals, which may not reflect trends in other healthcare settings. Second, the geographic focus is limited, potentially overlooking regional differences in the supply and demand for vitreoretinal surgery. Finally, the retrospective design may not capture the most recent trends or emerging changes in the field. Future research should extend to various hospitals across different regions to achieve a more representative and accurate assessment of the supply and demand for vitreoretinal surgery throughout China. The broader perspective study will elucidate regional differences and support more refined healthcare planning and policy decisions, ultimately to implement more cost-effective, efficient, and effective healthcare management for vitreoretinal diseases nationwide.

Conclusion

In conclusion, this retrospective study revealed a significant increase in vitreoretinal surgeries in China over the past decade, particularly for DR and MD. These trends reflect not only advancements in surgical instrumentation and imaging technologies, but also evolving demographic and healthcare dynamics, including an aging population and rising prevalence of diabetes and myopia. Furthermore, the findings emphasize the continued need for effective diabetic complication prevention and early detection initiatives. Our study provides critical insights for future workforce planning and predicting healthcare expenditures to address the increasing demand for vitreoretinal surgery.