Make Room for Retina

Innovative technology that enhances safety and efficiency has ASCs opening their doors for this subspecialty

Once considered too technically challenging and time-consuming to perform in an outpatient setting, retina surgery is making its way into the ASC setting. What is the impetus behind this change? In a word: technology.

“Advances in surgical retina in the last decade have been nothing short of phenomenal,” says Pravin U. Dugel, MD, managing partner of Retinal Consultants of Arizona and a founding member of Spectra Eye Institute, a multispecialty ophthalmic ASC in Sun City, AZ. “When I was in training, patients required general anesthesia and an overnight stay in the hospital. Surgeries could take several hours, and outcomes weren’t nearly as good as they are today. Now, our surgeries are faster and more efficient. We use local anesthesia and smaller gauge instruments. Sutures are rarely necessary, and recovery times are faster.”

It’s no wonder that ASC owners who are interested in growing their businesses often ask Dr. Dugel if now is a good time to include retina in their ASCs.

“That is a relevant question, but the answer is complex,” Dr. Dugel says. “Our surgeries are not only faster but also technologically more intense. The extent of training, skill, and technical proficiency that a retina surgeon needs is far greater today than a few years ago. In addition to a technically proficient surgeon who achieves consistently good outcomes, an ASC needs a surgeon who is aligned with its goals of delivering efficient, cost-effective care.”

ASC owners thinking about adding retina to their surgery centers also must be aware of the significant investment required for good instrumentation.

“Equipping an OR for retina — vitrectomy system, laser, gases, cryotherapy, handheld instruments — can cost upwards of $1 million per room,” Dr. Dugel says. “In a proper setting, you would have redundancy for all of that equipment to ensure appropriate patient care even if a machine breaks during surgery, which has happened to all of us. It’s a huge investment.”

If you’re ready to equip your new retina OR or if you anticipate upgrading some equipment in your existing OR, here are insights on some of the newer technologies and a peek at what’s to come.

Advances in Vitrectomy Systems

The vitrectomy system could be considered a cornerstone of the retina OR. Some recent advances in cutting technology, fluidics, and lighting have enhanced safety and efficiency.

The Ultravit 10k probe (Alcon), which is used with the Constellation Vision System (Alcon), has a beveled tip and delivers 10,000 cuts per minute (cpm) via dual pneumatic drive technology in 23, 25+, and 27+ gauges.

“These days, surgeons are using vitrectomy cutters as multifunctional tools, replacing other instruments, such as scissors,” says Paul Hahn, MD, PhD, NJRetina. “With the beveled cutter, the surgeon can safely operate close to the retina, and the faster cut rate reduces traction and the risk of iatrogenic tears.”

The EVA surgical system (Dutch Ophthalmic Research Center) features a VTi pump system that offers flow and vacuum fluidics and a two-dimensional cutting probe that cuts forward and backward at a maximum of 16,000 cpm. The system uses a high-powered LED light source, and Dutch recently introduced a high-flow infusion cannula designed to manage the increased flow generated by the system.

“The Dutch system incorporates two different types of pump systems into a custom setting the surgeon can adjust while operating,” Dr. Hahn says. “Surgeons who have used this system say it maximizes safety while working near the retina.”

The lightweight (~25 lbs.) VersaVit 2.0 vitrectomy system (Bausch + Lomb) has found its niche as a secondary system for the surgeons at NJRetina.

“The primary system in our ASC is the Constellation, and we use the VersaVit system as an important backup device if we’re running two rooms or if something happens with the primary device,” Dr. Hahn says. “While its functionality has some limitations compared with the larger machines, the VersaVit system is less expensive, reliable, portable, and equipped to handle most cases smoothly.”

Breaking news… Bausch + Lomb’s new vitrectomy system, Vitesse, will be available later this year as part of the new Stellaris Elite Vision System. Vitesse is a marked departure from the traditional pneumatically driven guillotine cutter in that it uses hypersonic energy to liquefy vitreous at the edge of a fixed 100% open port before aspiration.

“The core of what we do is cutting vitreous,” Dr. Hahn says, “and when we cut and remove vitreous, we’re always pulling on it and inducing traction, which can cause problems. Traditional cutters have addressed this by using faster cut rates and taking smaller and smaller bites to reduce the amount of traction. The Vitesse machine approaches vitrectomy in a completely different way by dissolving vitreous with minimal to no traction. This could be a game-changer in the way vitreous is addressed.”

According to Dr. Dugel, “The hypersonic cutter is intriguing because the technology it uses to remove vitreous is entirely different from what we’ve been doing for decades. It’s a new technology that still has to be matured, but I think it’s very exciting.”

Before You Open Your Checkbook

Dr. Dugel offers these tips to ASC owners contemplating equipment purchases for retina surgery:

  • Make sure your budget is healthy. Equipping an OR for retina surgery involves a significant investment, particularly because you’ll need to purchase two of almost everything.
  • Trust your surgeon. The most important independent variable related to an ASC’s success, i.e., profitability, is the surgeon. While the costs of vitrectomy systems may vary, it is in the ASC’s best interest to invest in the system the surgeon prefers, because the surgeon’s comfort with and confidence in his or her equipment affects outcomes and efficiency.
  • Make sure your inventory system is robust. Retina surgeons use many disposable items, all of which must be available in ample supply. The inventory management of disposables is extraordinarily difficult.

New Perspective on Visualization

Heads-up surgery — viewing the surgical field on a large high-definition screen instead of through the oculars of a microscope — isn’t new in medicine, but it is in vitreoretinal surgery. Last year, Alcon, in collaboration with TrueVision 3D Surgical, launched the Ngenuity 3D Visualization System, which converts an optical microscope into a digital imaging system.

Retina surgeons have reported the resolution of images on the Ngenuity screen are comparable to those viewed through the microscope, and the system enables surgeons to digitally apply color filters to enhance the view of tissue planes.

“Not only does Ngenuity allow digital control of magnification, surgeons can also digitally amplify gain, which allows operating with lower light levels to minimize the risk of phototoxicity to the retina,” Dr. Hahn explains. “In addition, this system provides an important digital platform to allow the surgeon to simultaneously display images imported from the clinic, such as OCT, and view them on-screen with the surgical field.

“Surgeons who use the Ngenuity system have reported that it’s easy to incorporate into practice,” Dr. Hahn says. “And although the cost may be high for some ASCs, it’s not as expensive as I expected it to be.

“There have been no major advances in microscopes in the past 50 years or so,” Dr. Hahn says. “The Ngenuity may be the next step toward advancing our microscope technology, and it may be a platform to incorporate other imaging devices as well.”

Dr. Dugel is not just AN early adopter but THE early adopter of heads-up vitreoretinal surgery.

“I was the first surgeon in the United States to perform vitreoretinal surgery using this technology, and I haven’t used a microscope in almost 3 years,” Dr. Dugel says. “In addition to providing better depth of field and visualization than the microscope, the Ngenuity system, with its huge screen, facilitates teaching and engages the OR staff in a way that’s not possible when we’re using the microscope. Heads-up surgery is also easier on your back and neck, because you’re not crouched over a microscope during surgery.”

On the horizon… Not satisfied with the status quo, Dr. Dugel has been exploring new ways to expand the utility of a heads-up 3D visualization system in retina.

“To me, the benefits that are currently being described are all secondary or even tertiary,” he says. “The reason I think this technology is exciting is because now we have a digitized image, and once you digitize an image, you can do whatever you want with it.”

Dr. Dugel has been researching and testing what he calls a “retina GPS,” which he likens to the strategy followed by airplane pilots, who map out their course before ever entering the cockpit.

“What I’m working on right now involves using image registration to place multimodal images, such as OCT, fundus photos, fluorescein and indocyanine green angiograms, exactly where they should be in a digitized format and then planning navigation so that as the eye moves, the multimodal images move with it,” Dr. Dugel explains. “Right now, when surgeons go into the OR, which is the most stressful time, they have very little information. All of those images are left behind. The initiative for what I’m doing is to be able to continue that information thread from the clinic to the OR.”

Dr. Dugel reports he has successfully conducted proof-of-concept studies. “I am convinced this will be the future standard in retina as it is in neurosurgery, for example. We are entering an age of informatics that will revolutionize retina surgery.” (See “Discovering Surgical 3D Camera Systems,” page 16.)

Other Advances to Consider

Not every innovation in retina is complex with a big price tag. Valved cannulas, for example, have made their way into the retina mainstream, Dr. Hahn says, with the majority of retinal surgeons likely using them. “A valved cannula is designed with a silicone cover to keep fluid from leaking out of the eye when the instruments are not in the cannula,” Dr. Hahn says. “It’s a simple concept, but it keeps the eye stable, and the difference in cost between a valved and a nonvalved cannula is nominal.”

The most recent introduction in small-gauge instrumentation is the 27-gauge vitrector. “I think 27-gauge is an emerging technology, and surgeons are being selective in when to use it,” Dr. Hahn says. “Twenty-seven gauge instruments provide perhaps better wound closure and better comfort for patients, and there are some advantages to using them for certain types of delicate surgery, such as in diabetic eyes where the smallest size instrument provides improved access. On the downside for surgeons, 27-gauge instruments are somewhat more flexible than the larger gauges, and there is less variety in the types of instrumentation available in 27-gauge. For an ASC, inventory management is an important consideration if their surgeons are using multiple gauges.”

Dr. Hahn believes most ASCs where retina surgeries are performed likely have noncontact wide-angle viewing systems, which allow surgeons to operate without needing an assistant to hold a bulky contact lens on the surface of the eye.

“One of the newer advantages of noncontact wide-angle technology is the ability to focus the device with a foot pedal, again eliminating the need for an assistant to dial a knob to focus and refocus during surgery,” Dr. Hahn says, noting that both the BIOM (Oculus) and the Resight (Zeiss) have incorporated this feature. “Wide-angle viewing systems are certainly more expensive than a single contact lens, but in my opinion, the initial investment is worthwhile for efficiency and the independence you have as a surgeon.” ■