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Article Date: 6/1/2002

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Diamonds Can Be a Surgeon's Best Friend
Three cataract surgeries a week can make diamond blades cost effective.
By Jerry Helzner, Associate Editor

If you went back to $25 metal blades after seeing your $3,000 diamond blade damaged beyond repair, it may be time to give diamonds another chance. And if you've never used a diamond blade in your cataract practice, it may be time to think about making the switch.

"Bottom-line issues are moving more and more surgery centers and hospitals to rethink the use of diamonds," says Brian Chandler, president of Accutome, a manufacturer of diamond surgical knives. "Aside from being cost-effective for most cataract surgeons, diamonds are the blade of choice because they're reusable, predictable and provide superior incisional qualities. And with manufacturers working hard to educate surgeons and their techs about the proper care and cleaning of diamond knives, the main challenge, reducing repair costs, is gradually being overcome."

Long-lasting diamond knives have traditionally been the choice of high-volume cataract surgeons who perform 50 or more procedures a month, as figures compiled annually for the American Society of Cataract and Refractive Surgery by David Leaming, M.D., indicate. However, proponents of diamonds contend that even if you're averaging as few as three cataract surgeries a week, using a diamond can offer you cost and quality advantages over inexpensive metal blades. In this article, we'll explore those advantages, keeping in mind the key role that care and maintenance play in making diamonds the cost-effective choice (see "TLC for Your Diamond Blades").


How surgeons choose

The great majority of the top cataract surgeons use diamond blades. John A. Bee, president and CEO of Rhein Medical Inc., which manufacturers and distributes both diamond and metal surgical knives, says he knows why.

"Diamonds are the gold standard of surgical knives," says Bee. "Surgeons understand technology. They know that the better the technology, the better the result. The elite surgeons want the sharpest blade they can buy."

Surgeon after surgeon interviewed for this article said diamonds give them a cleaner, more precise incision with less tearing of tissue.

Richard Ruckman, M.D., who performs about 1,000 cataract operations a year at his Center for Sight in Lufkin, Texas, says a diamond blade's clean incision heals faster and leads to fewer complications.

"First, a diamond blade enables me to do a high-quality operation," says Dr. Ruckman. "Second, with Medicare reimbursement for cataract surgery reaching critically low levels, particularly in states such as Texas, I want my patients to heal quickly and require fewer follow-up visits."

And Luther Fry, M.D., of Garden City, Kan., who performs about 40 cataract operations a week, says he likes the sharpness and consistency of diamonds.

"The newer stainless steel blades are quite good and consistently sharp on first use, but if you use them more than once, this consistency is lost," says Dr. Fry. (Note: Metal blades that are supplied sterile are labeled as single-use, but some surgeons use them for more than one procedure.)

Conversely, diamond blades will retain their sharpness almost indefinitely if they're cared for properly and rehoned when necessary. Charles Williamson, M.D., who helped pioneer clear corneal cataract surgery in the early 1990s and whose Williamson Eye Center in Baton Rouge, La., performs about 3,000 cataract procedures a year, says he still uses Diamatrix diamond knives purchased in 1994.

Ron Dykes, president of Diamatrix, which manufactures both metal and diamond blades, says diamond blades have come into their own in the last decade, as more surgeons have adopted the clear corneal technique for performing cataract surgery.

"The incisions involved in clear corneal surgery lend themselves to using a diamond blade," says Dykes. "With diamonds, the tissue proximates better and the incision causes less trauma. Diamond blades are definitely the best choice for the experienced cataract surgeon, and over time they'll always be the most cost-effective if they're cared for properly."

Experience counts

A cataract surgeon's experience and procedure volume are fairly accurate indicators of whether he uses a metal or diamond blade.

"You'll often find younger cataract surgeons using metal blades, usually for economic reasons and also because the metal blades aren't as sharp and provide a bit more margin for error," says John Bee of Rhein Medical. "For those surgeons who are currently using metal and might be thinking of making the switch to diamonds, a $1,200 to $1,400 synthetic black CVD (chemical vapor deposition) diamond blade is a good way to make the transition at about half the cost of a true gem diamond. The black diamonds are much sharper than stainless steel, but not quite as sharp as a true gem quality diamond."

Some surgeons recommend transitioning from metal to a thicker black diamond blade because these blades are more forgiving than thinner, sharper diamonds and provide some of the "feel" of a metal blade.

Alberto J. Aran, M.D., of Aran Eye Associates in Miami, has never used anything but a diamond blade.

"The surgeon I trained under during my residency at Tulane University Medical School always used a diamond," says Dr. Aran. "I never considered using anything but a diamond blade. They give you a much sharper, cleaner incision."

Aran, who performs 35 to 40 cataract operations a week, uses a true diamond blade for the groove and the sideport, and a black diamond to cut the corneal tunnel.

Strict protocols save blades

"We have six surgeons who share our diamond blades, but the surgeons and techs are trained to treat them with tender loving care," says Aran. "We have strict rules for handling and cleaning the blades so that they don't get damaged."

David Chang, M.D., clinical professor of ophthalmology at the University of California, San Francisco, and in private practice in Los Altos, Calif., performs about 1,000 cataract operations a year in a high-volume outpatient surgery center with 15 other anterior segment surgeons and a rotating staff of scrub nurses. Typically, this is just the type of difficult-to-police environment that leads to damaged diamond blades, but Dr. Chang and his colleagues have avoided this problem.

"The center shares the cost of diamond knives with each surgeon," says Dr. Chang. "If a surgeon's volume warrants it, the center provides an allowance for purchasing his or her own individual diamond knives. I have two identical sets of blades, which allows me to alternate between rooms. Each surgeon is responsible for handling, maintaining and repairing his or her own blades. This arrangement works well for both the surgeons and the center. The center reduces its costs by eliminating disposable blades, and uses some of the savings to defray the large initial investment in diamonds that each surgeon would otherwise have to make.

"Because we're financially responsible for any repairs, we all handle our diamonds very carefully and steam clean the blades ourselves at the end of the day," he continues. "No nurses or techs are involved in the cleaning. With this protocol, we don't have any mysteriously damaged blades that can end up being blamed on the center's staff."

If you perform cataract procedures in a high-volume surgery center or hospital, an arrangement such as Dr. Chang has may work for you as well.

Learning has been key

Almost all of the surgeons and industry executives interviewed by Ophthalmology Management for this article agree: Whether you're doing three cataract surgeries a week or 30, using diamond blades can bring benefits. At three surgeries a week, you won't get much of a cost benefit, but you will be operating with a high-performance blade.

A decade of experience with diamond knives has taught both surgeons and manufacturers how to care for these blades so that damage can be minimized, or even eliminated. The major manufacturers have increased their training efforts and now provide a wide range of support services designed to make it easy for practices and surgery centers to choose diamond blades. For their part, the surgeons and centers have learned to establish strict protocols for the handling, care and cleaning of their diamond knives.

Given the learning that's occurred -- and the resources that are now available to you as a surgeon -- it's likely that if you tried diamonds before and gave up on them, you'll have a much better experience the second time around.



"TLC" for Your Diamond Blades


Surgeon Alberto J. Aran, M.D., of Aran Eye Associates in Miami, says he and his staff treat their diamond knives with "tender loving care." By enforcing strict rules regarding the care and cleaning of these expensive instruments, Dr. Aran has been able to avoid the high repair and blade replacement costs that can negate the cost-effectiveness of diamonds. One key rule that Dr. Aran's staff follows: Never hold a diamond blade while you have anything else in your hand.

Here are 10 more suggestions from surgeons and diamond blade manufacturers that should help give your diamond blades a long and useful life:

  • Never let your diamond blades touch anything but tissue or liquid.

  • All diamond blades have protective shields. Make sure the shield is in place immediately before and immediately after you use the blade. Only the surgeon should extend and retract the blade during surgery.

  • Because most diamond blades get "dinged" by banging against another instrument during surgery, you'll reduce the chances of that happening by using fixation rings and sideport fixators. These are "complementary" instruments that keep diamond blades from being damaged.

  • Diamond blade manufacturers are eager to help you use their blades in a cost-effective manner. Ask your blade manufacturer to send a representative to observe your surgical and blade care procedures. This trained observer can point out anything you or your staff is doing that presents a hazard to your blade. "If you're a left-handed surgeon, we can tell you specifically how you're likely to damage a blade, and we can do the same thing for a right-handed surgeon," says Ron Dykes, president of blade manufacturer Diamatrix.

  • Just before going on vacation, send your diamond blades to the manufacturer for inspection. What you think might be damage may just be a blade in need of a thorough cleaning or a routine rehoning. Manufacturers provide quick turnaround and will have the blades back to you in a few days.

  • If you're sharing blades with other surgeons, you must take special precautions. Limit the number of people who can handle the blades and make one tech responsible for proper blade cleaning. In blade-sharing situations, education and enforcing strict rules are the keys to avoiding blade damage. Here again, ask the blade manufacturer to come in and make recommendations for protecting the blades.

  • No one has come up with a single "right way" to clean diamond blades. Richard Ruckman, M.D., suggests making one person responsible for blade care. He recommends rinsing the blade in distilled water immediately after each use, then filling your ultrasound unit with ammoniated jewelry cleaner and giving the blade a 30-second bath under low power. Then rinse the blade again in distilled water and use a high-pressure steam cleaner to remove residual protein. Finally, follow standard disinfecting and sterilization procedures.

  • Rhein Medical is now offering an innovation for cleaning diamond (or any other) blades. It's a small tray that holds three pre-packaged pads. One pad contains a cleaning solution. The other two are soaked with de-ionized water and serve as rinses. Run the blade through the three pads in sequence and then sterilize the blade. John Bee of Rhein Medical says the easy-to-use cleaning system has been well-received by surgeons.

  • Take advantage of the blade care training sessions that are offered at the American Academy of Ophthalmology and American Society of Cataract and Refractive Surgery conventions, as well as at some smaller meetings. Whoever attends these sessions will be able to return to your surgical facility and teach the other staff members.

  • Once your blade care protocol is established, never deviate from it.



Ophthamology Management, Issue: June 2002