Article

Retina Surgery on the Move

Advances in instrumentation fuel the trend toward ASC procedures.

Retina Surgery on the Move
Advances in instrumentation fuel the trend toward ASC procedures.
By Eddie F. Kadrmas, M.D., Ph.D.

In the March 2001 issue of Ophthalmology Management, I wrote an article about the benefits of moving vitreoretinal surgery from the hospital setting to the ASC. ("About Time? Vitreoretinal Surgery in the ASC," page 38.) I am happy to say that in December 2002, my experiences on that front are still overwhelmingly positive. As I stated in the first article, once one becomes accustomed to operating in this setting, there is no desire to go back to the ways of the past.

I have received communications from a number of retinal specialists, from California to Massachusetts and from North Dakota to Florida, expressing their desire to set up their own retina ASCs. Many of them have done so. Retina surgery in the ASC is certainly alive and well and continues to grow in popularity.

This is due in part to the amazing advancement in surgical technology, which is making procedures safer for our patients, as well as more cost- and time-efficient for us. The following pages provide an overview of what we've been working with in our practice, as well as a list of new tools available to vitreoretinal surgeons.

Patients and surgeons benefit

High-speed vitreous cutters, such as those manufactured by Bausch & Lomb, Alcon and Dutch Ophthalmic Research Center, have decreased vitrectomy times significantly and have, most importantly, made the procedure more precise and safer for the patient. Other companies, too, such as Synergetics, have been developing instrumentation that improves quality of care and convenience for patients, and streamlines procedures and minimizes personnel and overhead costs for surgeons -- all factors that foster the movement toward ASCs.

For the past several months, I've had the opportunity to work with B&L's Millennium TSV25 System. This 25-gauge transconjunctival standard vitrectomy system was developed by Eugene de Juan, Jr., M.D., and colleagues at the Microsurgery Advanced Design Laboratory at the Doheny Eye Institute of the University of Southern California. It streamlines procedures by allowing surgeons to operate through a self-sealing microincision. The system thereby eliminates dissection of the conjunctiva and the creation of standard scleral incisions.

Its entry alignment cannulas allow the use of an array of newly developed instruments, including a 25-gauge high-speed cutter. Once the main portion of the procedure is complete, there is no need to suture the sclerotomies, as the wounds are sealed to fluid as well as intraocular gas. Dr. de Juan and colleagues explained the advantages of the system in two articles published in the October issue of the journal Ophthalmology. The system obviously has tremendous implications for retina surgery in the ASC setting, they stated, allowing surgeons to operate "more swiftly, more efficiently, and more cost-effectively."

Although not all retina surgical procedures lend themselves to the use of this system, it appears to be ideal for some of the more common procedures we perform, such as surgical management of macular puckers, macular holes, vitreomacular traction, some diabetic traction detachments and some simple rhegmatogenous detachments. It may also be ideal for some of the newer procedures, such as radial optic neurotomy for central retinal vein occlusion and arteriovenous sheathotomy for branch retinal vein occlusion. It's useful in some pediatric cases, too, because the small instrumentation is ideal for small eyes.

In cases that require larger instrumentation than will fit through the 25-gauge cannulas, I've still been able to use the TSV25 system, by performing a limited peritomy and enlarging a sclerotomy. Although this requires closure of the tissues, I find that it does not make the case significantly less efficient.

Assessing the limitations

As with any new technology, however, there is a learning curve, and instrumentation and techniques need to be designed and refined. Current instrumentation is somewhat limited for the TSV25 system. For example, as of this writing, Bausch & Lomb has not released an endolaser probe for clinical use. As of late October, however, a laser probe is available from Synergetics, in addition to an endoilluminator and other instruments for 25-gauge use.

Recently, I spoke with Michael Trese, M.D., of the Associated Retinal Surgeons in Royal Oak, Mich. Dr. Trese has extensive experience with the TSV25 system, and he feels that although the 25-gauge high-speed cutter is faster than a traditional 20-gauge cutter, the smaller lumen of the instrument requires the system to run on relatively high aspiration. This slows the cutter down compared with its 20-gauge counterpart.

Also, the smaller port tends to get clogged when he's performing a vitrectomy with admixed hemorrhage. Dr. Trese feels that enzymatic vitreolysis will solve this problem and also play an important role in future vitreous surgery, especially when used with a 25-gauge system. He has used autologous plasmin enzyme for this purpose and has found it to work well. He is currently devising a kit for general use by retina specialists. Dr. Trese says that vitrectomy with the use of plasmin in essence becomes more aspiration than cutting. Hyaluronidase is also under study for this purpose.

Is in-office surgery a possibility?

Dr. Trese believes that the combination of 25-gauge surgery and enzymatic vitreolysis will eventually make it possible for us to perform vitreoretinal surgery in-office. A big obstacle there, he says, are the current regulations governing facility approval and accreditation.

"It will take a major change in the structure of the current system before in-office surgery can be a reality," he says. "Maybe once payers realize the cost savings that can take place, things will change."

In the meantime, retina surgery in an ASC, when it can be done, is clearly the way to go for many surgeons. And further incentive from Medicare and other third-party payers wouldn't hurt that effort either. Based on the progress made so far, retina surgery will follow cataract surgery to the ASC, where patient- and physician-friendly, cost-effective care is at its best.

Eddie F. Kadrmas, M.D., Ph.D., is a vitreoretinal surgeon in private practice in Plymouth and Dartmouth, Mass. He is an Instructor in Ophthalmology at Harvard Medical School and a member of the Editorial Board for Ophthalmology Management. He has no financial interest in any of the products mentioned in this article.

Michael T. Trese, M.D., is a vitreoretinal surgeon with Associated Retina Consultants in Royal Oak, Mich. He is a Clinical Professor of Biomedical Sciences at Oakland University and a Clinical Associate Professor of Ophthalmology at Wayne State University. He has financial interest in the commercial development of autologous plasmin.

 

Updating Your Armamentarium

FROM ALCON:

  • The upgraded Accurus Surgical System -- XS4 with 3D Technology -- improves surgeon control to make posterior, anterior and combined surgeries more efficient. 3D Technology enables simultaneous change of cut rate and vacuum with the foot treadle in one easy step. It's designed to be easy to use by providing an intuitive way to easily change flow rates dependent on various target tissues throughout surgery.
    To get higher flow, just depress the treadle, which will increase vacuum and decrease cut rate. To lower flow, release the treadle to lower vacuum and increase cut rate.
  • The Accurus Surgical System offers a wide range of pneumatic probe technologies designed for ultimate surgeon control. The high-performance probes reduce traction and increase stability for cutting close to the retina. The family of vitrectomy probes includes the traditional guillotine design and the InnoVit with its radial reciprocating action. Both Accurus and InnoVit probes allow exceptional tissue manipulation. Cut rates up to 2,500 cuts per minute are possible.
  • Five scissors and forceps make up the Grieshaber Revolution platform. These instruments are the result of a collaborative effort by the Grieshaber Research and Development group and the Duke University Eye Center Biophysics Laboratory to develop a new generation of handheld instrumentation. The result of this relationship is instruments that provide 360-degree actuation, optimized lever travel and exceptional balance.

FROM DUTCH OPHTHALMIC USA (a subsidiary of the Dutch Ophthalmic Research Center):

  • DORC has introduced a complete line of 25-gauge instruments and accessories for transconjunctival vitrectomy. The highlight of this system is a 25-gauge guillotine vitrectomy cutter that is compatible with most vitrectomy systems, including Alcon Accurus and B&L Millennium. Also available in 25-gauge is the TotalView Endoillumination Probe, the new asymmetrical forceps, the Eckardt ILM forceps, and curved horizontal and vertical scissors.

The 20-gauge disposable Self-Retaining Infusion Cannula is a time-saver because it makes sutureless fixation possible.

  • DORC Disposable Lenses are manufactured of optically clear silicone, which provides excellent visualization. Each lens integrates a self-retaining ring, which, combined with a small amount of viscoelastic, keeps the lens in place without sutures or manual handling. The lenses are sold sterile, 5 per box, and are available in flat, biconcave, magnifying, wide-field and 30° prism styles. They're an alternative to reusable lenses, which can become obscured by water spots and scratches.

Dutch Ophthalmic's disposable lenses can complement any 25-gauge surgical system.

  • The new, 20-gauge disposable Self-Retaining Infusion Cannula makes sutureless fixation possible. A retaining ridge on the shaft captures the lips of the sclerotomy intraocularly, while a round platform stabilizes the cannula against the sclera. Sold sterile, 5 per box.

FROM SYNERGETICS:

  • Synergetics, Inc. has developed disposable and reusable instrumentation for use with 25-gauge trocar systems, including the 25-gauge Kryptonite Microserrated Tano Asymmetrical Forceps. These forceps feature an asymmetrical tip, allowing absolute viewing of the tip. Manufactured with Kryptonite, their perfectly matched microserrations provide a superior grasping surface.
  • The 25-gauge Diamond Black Microserrated Curved No-slip Scissors are the only 25-gauge curved scissors available. The serrated jaws prevent tissue expulsion during cutting.
  • The 25-gauge Awh Serrated Pick offers all of the features of a traditional pick, with the addition of negatively canted serrations, which provide frictional grasping on the top surface.
  • The 25-gauge Disposable Endo Illuminator is produced with a proprietary fiber drawing method that delivers approximately 4 times the illumination of other 25-gauge illuminators.
  • The 25-gauge Directional Laser Probe allows the surgeon to custom curve the probe through axial movement of a slide button on the handpiece. This provides a straight or severely curved probe, making it ideal for addressing all surgical geometries.
  • The 25-gauge Tano Diamond Dusted Membrane Scraper simplifies ILM removal and lifting the edge of fine ERM.
  • The 25-gauge Awh Flexible Hemostat has a soft silicone ball tip on a flexible silicone extension for use as an atraumatic tamponade virtually anywhere.
  • The 25-gauge Bipolar Cautery is compatible with all bipolar cautery units. Heating occurs at the tip of the extended wire.

FROM VOLK OPTICAL:

  • The Reinverting Optical Lens System (ROLS) uses Volk's contact vitrectomy lenses to provide a wider field of view than noncontact designs. The ROLS system has a patented single-element reinverter prism, is simple to install and operate, and can be used with any style of operating microscope.

ClariVit lenses, among others from Volk, are now autoclavable.

  • With its new ACS product line, Volk now offers autoclavable lenses, including the Chalam SSV and standard and ClariVit styles. The ACS line includes lenses for direct and indirect high magnification as well as indirect ultrawide-field vitrectomy lenses. Autoclavable lenses help to speed up processing time in the operating room by eliminating the need for ETO gas sterilization. The new vitrectomy lenses can also withstand exposure to bleach and alcohol.