Article Date: 6/1/2013

VersaVIT for Vitrectomy

VersaVIT for Vitrectomy

Full functionality, efficiency and portability at an affordable cost

John W. Kitchens, MD (moderator): What is your primary consideration when you’re purchasing a vitreoretinal surgery system for your facility?

Derek Y. Kunimoto, MD, JD: I operate in a surgical center where space is a constraint. Therefore, having a machine we can use for both anterior and posterior surgeries is an important consideration for us. Cost is another factor, and, of course, performance.

Geeta A. Lalwani, MD: In addition to the cost of the machine itself, it’s important to consider the costs of service and surgery packs. Another aspect that came up for me recently is the desire to have a back-up machine available in case there are any issues. In the absence of a significant difference in performance, more cost effective machines become very compelling.

Byron Ladd, MD: My primary concern is the machine has to perform well. Once this is satisfied, then cost, service and reliability are important considerations.

CAPITAL EXPENSE VS. OPERATING EXPENSE

Dr. Kitchens: Is the capital expense or the operating expense more important to you?

Rohit Ross Lakhanpal, MD: We recently experienced this firsthand at our surgery center. Choosing a system with lower pack prices rather than one with a lower initial capital cost is a better decision in the long term.

Charles C. Wykoff, MD, PhD: I operate in a hospital, not an ASC, so capital cost vs. operating cost is a secondary consideration in my mind. I like to use a vitreoretinal system that works reliably and allows me to do whatever I need to with the same machine. Reliability figures prominently into the performance issue.

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Also, in my experience, surgical technicians, especially if new or inexperienced, can struggle with complex surgical machines such as the Alcon Constellation, our primary vitrectomy machine. At my primary hospital, liability concerns make it challenging to bring in new types of equipment and machines. It would be ideal to operate in a facility where such obstacles did not limit exposure to new equipment.

Dr. Ladd: Most of our contracts have been structured so the cost of the machine is amortized in the pack price over the life of the contract. This reduces initial capital expenses but requires accurate predictions of surgical volume. As an owner in our ASC, reducing capital expense is a financial benefit.

Dr. Kunimoto: We actually analyzed this where I operate, and we found that, by far, pack price is a bigger driver in the long run — over 10 years, by a factor of 8 to 10 times over the capital expenditure for the equipment. We focus all of our negotiating around pack price.

ADDRESSING SPACE CONSTRAINTS AND EASE OF USE

Dr. Kitchens: Does your operating staff provide feedback about the ease of use of your vitrectomy system? Does that affect your choice?

Audina M. Berrocal, MD: At Bascom Palmer Eye Institute, when we switched from the Accurus to the Constellation, the learning curve for staff members was huge. Even today, after using the Constellation for 3 or 4 years, if a younger scrub nurse or someone inexperienced with retina is on the case, there’s always a glitch. Would it be nice to work with the same scrub nurse for every case? Yes, but that’s not practical in this day and age.

Anton Orlin, MD: At Cornell, we transitioned from the Accurus to Constellation last year. Although initially, this transition was difficult for the OR staff, but it has become easier for them to operate with experience. Now, when compared to the Accurus, it seems to be easier to set up and to go through a case.

Is it Advantageous to Have Two Different Vitrectomy Machines?

Rohit Ross Lakhanpal, MD: We have a Constellation, which we bought after the Stellaris so we would have two systems. Machines each have their advantages and disadvantages, and most surgeons have a preference. In our practice, some prefer the Constellation and others prefer the Stellaris. Looking back, perhaps we should have waited and chosen the VersaVIT as our backup. It’s easier to use, portable and much less expensive. I don’t think anyone needs to buy a $100,000 system, or whatever high cost it would be, as a second system.

Derek Y. Kunimoto, MD, JD: We considered buying two different systems in order to attract new surgeons to our center. We ultimately made a strategic decision to go with one machine. From our standpoint, it was helpful to put all of our eggs in one basket, so we could negotiate better pack prices. We could promise higher volumes with the one machine.

R.V. Paul Chan, MD, FACS: For those of us involved with training fellows, having multiple platforms can be beneficial. Many of us trained on just one platform and the hospitals or ASCs where we ended up working didn’t necessarily have the same platform.

Thomas A. Albini, MD: I agree. Fellows are actively seeking out experiences on multiple platforms, not only to determine what they like best but also to be adaptable to multiple environments.

Byron Ladd, MD: We’re in a situation where we just finished a 5-year contract with Alcon and we own our two Accurus systems. We renegotiated and decided it did not make sense financially to pay the increased pack price for the Constellation. As a result, we now have competing pack prices from Alcon and Synergetics for the Accurus. Since the VersaPACKs are compatible with the Accurus, there are performance and financial gains with use of VersaPACKs.

We have fewer glitches than we did a couple of years ago, and I think that aspect is important for choosing a machine.

Dr. Lalwani: Ease of use becomes a huge factor if you’re going back and forth between two different machines. The back-up machine should be very user-friendly as well. Otherwise, you have to begin from scratch teaching people how to use it.

Dr. Kitchens: Is the footprint or the dimensions of your vitrectomy system more important to you and your operating room staff? Does it depend on whether you are in a main operating room or an ASC?

Dr. Orlin: We don’t operate in an ASC at Cornell, so I don’t have much experience with one. At our hospital, I do not think that the size of the machine has played a big role in our surgeries, although with a smaller OR, I can see this playing a role.

Dr. Lakhanpal: In our ASC, we have the Constellation and the Bausch + Lomb Stellaris. We have an operating room and a procedure room. The Constellation is significantly larger than the Stellaris. That doesn’t make a big difference for me, but it can be quite cumbersome for the staff in the smaller procedure room.

Dr. Kunimoto: Our surgery center has space constraints, so part of our decision in choosing which vitrectomy system to purchase was driven by the footprint size.

Thomas A. Albini, MD: Although we have space to store the five Constellation systems we own in our hospital setting, it’s unwieldy to maneuver that machine down the hallway from one room to another. Having a smaller machine would be a benefit in those rare instances when a replacement machine is needed. Also, we’ve had combination anterior/posterior cases in which the other surgeon preferred the Alcon Infiniti system for phacoemulsification instead of the Constellation. Having two large machines in one room, even if it’s a large operating room, can be cumbersome. Having the smaller VersaVIT would be helpful in that regard.

Dr. Ladd: Since we began operating in our ASC 10 years ago, some of the hospitals we used to operate in are no longer functional for us because they haven’t kept up with equipment advances. Having a portable machine allows us to take equipment we’re comfortable with to those hospitals if we have to operate on a weekend.

R.V. Paul Chan, MD, FACS: As we continue to shift away from operating at larger institutions, we have to think about the potential benefits of having a second machine that is portable, and perhaps less expensive than buying two large units, but provides quality performance. There are also certain international considerations we should take into account as a more portable machine may be beneficial for those who work in developing countries.

Dr. Berrocal: Another point I would make is if the operating room’s microscope is on the floor rather than ceiling-mounted, it’s difficult to fit the scope, the assistant system, the scrub tech and the Constellation. Also, in rooms where we have femtosecond lasers, it’s almost impossible to use the Constellation.

VERSAVIT VS. OTHER AVAILABLE SYSTEMS: INSIDE AND OUTSIDE THE EYE

Dr. Kitchens: What factors motivated you to try the VersaVIT vitrectomy machine?

Dr. Albini: As a teaching institution, we were motivated primarily by the benefits of having a variety of machines available for fellows to use. Another motivating factor was the advantage in negotiating pack prices. Furthermore, efficiency was a concern. We want to have the proper machine for the job, and simpler cases don’t require the highest level of sophistication. Many cases can be done less expensively on a smaller machine with a smaller footprint. Also, as previously mentioned, portability is often an advantage. Therefore, as we considered what equipment to purchase, we expected the VersaVIT would allow us to be more efficient and add quite a bit of flexibility and agility to our practice.

Dr. Ladd: I’m always looking for ways to drive down the cost per case in our ASC. I will test anything new that comes out, and adopt it if it performs with the right price. I first checked into the VersaVIT to see how it functions and whether it could replace our Accurus if necessary. I feel very comfortable that the VersaVIT can replace the Accurus and provides the added benefit of portability. However, since we currently own our Accurus, it makes sense to use the VersaPACKs.

The VersaVIT definitely exceeded my expectations beginning with the start of the case. The trocar/cannula insertion system is phenomenal. A magnetic device holds the cannula in place so it’s not falling off, which occasionally happens with other systems.

— Byron Ladd, MD

Andrew A. Moshfeghi, MD: I was dubious about the capabilities of the VersaVIT when it was first introduced, but I had the opportunity to use it for one day’s worth of cases. I was interested to try it because it is indeed a very different machine, not a “me too” product like the Stellaris and the Constellation, which offer similar features. I also have an interest in research, and VersaVIT is an inexpensive way to perform animal vitrectomies.

Removal of vitreous is very smooth and efficient [with the VersaVIT]. I was impressed with the cut rate as well, and how the machine operated out of such a small footprint.

— Andrew Moshfeghi, MD

Dr. Kitchens: What were your first impressions of the VersaVIT? Did it meet or exceed those expectations?

Dr. Moshfeghi: I noticed first just how similar the fluidics were compared with what I was accustomed to using, which is the Constellation. Removal of vitreous is very smooth and efficient. I was impressed with the cut rate as well, and how the machine operated out of such a small footprint.

Dr. Ladd: The VersaVIT definitely exceeded my expectations beginning with the start of the case. The trocar/cannula insertion system is phenomenal. A magnetic device holds the cannula in place so it’s not falling off, which occasionally happens with other systems. The funnel-shaped opening of the cannula makes it easier to insert instruments. The light pipe doesn’t kink when it comes out of the package, which means the cord doesn’t flop around hitting the scope. All of these features are very nice.

Inside the eye, I believe the fluidics with a larger port are better than the Accurus. In my opinion, the VersaVIT light source and cutter perform equally as well, or better than, those parts of the Accurus. Finally, the ease of setup and takedown helps with turnover time, which is important in an ASC and enhanced my experience.

Dr. Albini: During our demo of the machine, it seemed relatively easy to set up. Feedback from staff confirmed there were no hurdles in terms of setup. Both the trocars and fluidics of the VersaVIT are perfectly adequate. My overall first impression was that I would continue to use the Constellation in difficult cases. However, I feel VersaVIT is a very good machine for straightforward cases, and I may feel more comfortable using it for more difficult cases as time progresses.

Dr. Kitchens: What is your assessment of the overall quality and performance of the VersaVIT system and its components?

Dr. Ladd: It works very well; the quality is very good. The trocar/cannula insertion system is as good as that provided in the Accurus. The blades are sharp, and insertion is easy. The light source is very good, too, and the cutter is seamless. I didn’t feel as if I was using a different cutter.

Another aspect that came up for me recently is the desire to have a back up machine available in case there are any issues. In the absence of a significant difference in performance, more cost effective machines become very compelling.

— Geeta A. Lalwani, MD

Dr. Kitchens: How would you rate the fluidics of the VersaVIT?

Dr. Moshfeghi: The VersaVIT fluidics are very similar to the Accurus fluidics, perhaps a little better. I also use the Constellation, and obviously it has additional bells and whistles to which I am accustomed, such as automation, and so on. However, as far as the actual vitrectomy is concerned, the VersaVIT is comfortable, easy to use and ergonomically designed. I don’t feel as if I’m using an inferior vitrectomy unit, which is somewhat surprising given the small size of the device.

Dr. Albini: In certain situations, especially working very close to the retina, stripping membranes and so forth with the cutter, I feel more comfortable with a 5,000-cpm machine.

Dr. Moshfeghi: Yes. The cut rate from the Constellation compared to the VersaVIT is certainly different, but comparing Accurus and VersaVIT, they are nearly equal. The VersaVIT cartridges fill up relatively quickly and have to be emptied, which is a straightforward step for the technician, but it does necessitate a bit of a pause.

Dr. Albini: I perform many diagnostic vitrectomies in my practice, and the small-cannister chamber is a convenient way to pass off a specimen for culture or other analysis.

Dr. Kitchens: With the MID Labs cutter, the port location is closer to the tip, and the port dimensions are larger. Are those features helpful during core vitrectomy?

Dr. Albini: They help to move more vitreous more efficiently.

Dr. Ladd: I think the larger port size is precisely the reason for the favorable fluidics.

Dr. Moshfeghi: I could see how the larger port size would be helpful in certain cases, such as a difficult diabetic with a chronic hemorrhage.

As far as the actual vitrectomy is concerned, the VersaVIT is comfortable, easy to use and ergonomically designed. I don’t feel as if I’m using an inferior vitrectomy unit, which is somewhat surprising given the small size of the device.

—Andrew Moshfeghi, MD

Dr. Kitchens: How would you rate the LED light source built into the VersaVIT?

Dr. Moshfeghi: The built-in LED light source is adequate for the vitrectomy, and the hue of the light has a very natural appearance.

Dr. Ladd: The dual-port LED light source provides plenty of light and I liked the hue being less yellow.

Dr. Albini: I have found the light to be non-problematic. It works well.

Dr. Kitchens: Can you describe a clinical condition you’ve treated where the VersaVIT met or exceeded your expectations?

Dr. Albini: At least in the beginning, I found the machine most useful for small procedures where opening an entire Constellation pack would be unnecessary. A procedure I put in that category, for example, is a Retisert (fluocinolone acetonide intravitreal implant, Bausch+ Lomb) placement or exchange where an infusion line is needed but a full vitrectomy is unlikely. Other examples are nonclearing vitreous hemorrhages and cases that require only a core vitrectomy and lifting of the hyloid or cases where the hyaloid is already elevated. Those cases are likely accomplished more efficiently with this machine. For diagnostic procedures as well, the VersaVIT is useful and perhaps more economically efficient than other options.

Dr. Ladd: Core vitrectomy goes faster than what I was used to with the Accurus.

Dr. Kitchens: In what percentage of your cases can you use the VersaVIT?

Dr. Moshfeghi: I don’t know that I would choose individual cases where I would use one machine and individual cases where I would use another. I would say the VersaVIT is capable of being a primary vitrectomy machine, and I think the decision on how to use it should be more about whether it should be the machine for a specified location. In other words, if you operate in more than one location — a hospital, surgery center A and surgery center B — you might have a Constellation at one and a VersaVIT at another.

Dr. Kitchens: Do you think you could use VersaVIT for 80% to 90% of your cases?

Dr. Moshfeghi: I don’t see any reason you couldn’t use it for all of your cases.

Dr. Ladd: VersaVIT can’t be used for injecting silicone oil, so in those cases a different instrument would be needed. I haven’t had the opportunity to use VersaVIT on a tractional diabetic membrane, but I’m eager to see its ability there. If it performs as I would expect, I think I could use it in 100% of my cases, except for injecting silicone oil.

Dr. Albini: I estimate that in my practice the number would be around 30% of cases.

How Would You Describe the VersaVIT to a Colleague?

Andrew A. Moshfeghi, MD: I would describe the VersaVIT as being as good as the Alcon Accurus in many respects, with a much smaller footprint and a potentially much lower cost of utilization. If I had to describe it in one word, it would be “efficient.”

Byron Ladd, MD: My word of choice would be “seamless.” Switching from the Accurus, you don’t realize you are using a different machine.

Thomas A. Albini, MD: I would point out that the VersaVIT has a smaller footprint and is more efficient than other available options. It provides the essentials for routine cases. I was pleasantly surprised by the way it performs.



I think efficiency is a great word to describe the experience with the VersaVIT, and it’s efficient in more than one way. It is an efficient remover of vitreous. It is efficient in terms of the finances related to pack costs and the acquisition cost of the machine as well as in footprint. It’s efficient in many ways.

—Andrew Moshfeghi, MD

Dr. Kitchens: There has been some indication that Synergetics is planning to introduce an enhancement package for the VersaVIT that would enable a 5,000-cpm, or perhaps a 7,500-cpm, cut rate.

Dr. Moshfeghi: Having a 7,500-cpm cut rate would be helpful in a situation such as a complex rhegmatogenous retinal detachment case.

Dr. Albini: Yes, for difficult cases when I am stripping tissue off the retina, working very close to the retina, I prefer the 5,000-cpm cut rate. If the VersaVIT became capable of 7,500 cpm, the “proof” would have to be “in the pudding.” If it’s effective, and I like it, VersaVIT might be the better machine. Or it might be equivalent to a 5,000-cpm machine, but a more efficient machine that accomplishes the same thing.

A SENSIBLE OPTION IN ANY SETTING

Dr. Kitchens: Does anyone have any final comments about the VersaVIT vitrectomy machine?

Dr. Albini: I was pleasantly surprised with the way it performed, and I would echo the previous comments that it performs similarly to the Accurus. I do think it is important to have multiple platforms to choose from in a practice. It fosters competition among different vendors. It also provides the flexibility to choose the best machine for a particular patient, and I don’t think the most complicated, most sophisticated machine is the right one for every patient.

Dr. Ladd: As cost per case becomes more important, the VersaVIT will become a major player. If the manufacturer can deliver an add-on to enable oil injection, surgeons would feel comfortable with it as their only and primary machine. Right now, that reluctance exists.

Dr. Moshfeghi: I think efficiency is a great word to describe the experience with the VersaVIT, and it’s efficient in more than one way. It is an efficient remover of vitreous. It is efficient in terms of the finances related to pack costs and the acquisition cost of the machine as well as in footprint. It’s efficient in many ways.

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Retinal Physician, Issue: June 2013