Article

What’s New in Vitreoretinal Instrumentation?

New designs, cut rates, and port migration aim to increase efficiency.

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The vitreoretinal surgical armamentarium is undergoing constant expansion due to the development of new technologies that increase safety and surgical efficacy. These developments include new cutter designs with larger port areas, higher cut rates to reduce traction, and port migration to allow them to be used as dissecting instruments. Additionally, the novel design of forceps, surgical lenses, and laser probes might reduce the amount of trauma to the eye and enhance surgical efficiency. Using information sourced from manufacturer websites, this review seeks to provide an overview of what is new in technological evolution for vitreoretinal surgeons. Whenever available, links with product information are provided.

CUTTERS

Advanced Ultravit High-Speed Beveled Probe

The Advanced Ultravit High-Speed Beveled Probe (Alcon) has a beveled-tip design that allows the cutting port to come closer to the retina (Figure 1). This high-speed probe delivers 10,000 cuts per minute (cpm) via a dual pneumatic drive technology, and it comes in 23-, 25-, and 27-gauge series.

Figure 1. The Advanced Ultravit High-Speed Beveled Probe (Alcon) features a beveled tip design, which enables the cutter port to get closer to the retina.

The distance between the bottom of the probe and the port opening is smaller on the new bevel-tipped probes than on the flat-tipped probes, measuring just 0.009 inches (0.23 mm) for all probes in the series (Table 1) (https://www.alcon.com/news/media-releases/alcon-launches-two-new-vitrectomy-technologies-help-improve-patient-care ).

Table 1: Tip-to-Port Distance in Alcon Standard and Ultravit Bevelled-Tip Probes
PROBE TIP-TO-PORT DISTANCE: STANDARD TIP TIP-TO-PORT DISTANCE: BEVELLED TIP % Δ
23 gauge .020 inches .009 inches 55%
25 gauge .017 inches .009 inches 47%
27 gauge .015 inches .009 inches 40%
% Δ, reduction of the distance between the cutting port and retina.

Carolina L. M. Francisconi, MD, is a vitreoretinal surgery fellow at St. Michael’s Hospital, University of Toronto, Canada. David R. Chow, MD, FRCSC, is an assistant professor in the Department of Ophthalmology and Vision Sciences at St. Michael’s Hospital, University of Toronto, and the director of the Toronto Retina Institute in Toronto, Canada. Dr. Francisconi reports no related disclosures. Dr. Chow reports consultancy to Alcon, Katalyst, Bayer, Allergan, Novartis, and DORC International. Reach Dr. Francisconi at lampertmontc@smh.ca.
Editor’s note: This article is featured in a journal club episode of Straight From the Cutter’s Mouth: A Retina Podcast. Listen to the episode at www.retinapodcast.com .

Two-Dimensional Cutting

The concept of a double-action surgical cutting probe involves 2 cutter openings in the guillotine shaft, thereby performing a cutting action on both forward and backward strokes of the probe. Regarding efficiency, the 2-dimensional cutter (TDC; DORC International) has a 92% duty cycle that creates constant aspiration flow independent of cutting speed, and its aspiration flow is 3 times greater than that of standard cutters. Also, the TDC reduces “surge” turbulence at aspiration from constant opening of the aspiration port. The main advantages of this design include a doubling of the cut rate, increased flow, and potentially decreased retinal traction.

The TDC also has higher performance for removal of tough tissues, such as lens fragments and thick membranes, due to its 42 PSI (~290 kPa) of working pressure. It is also available in 23-, 25-, and 27-gauge (https://www.dorc.eu/eva ).

Bi-Blade Dual Port

The Stellaris Elite system (Bausch + Lomb) will offer a new 25- and 27-gauge Bi-Blade vitrectomy cutter that can create up to 15,000 cpm and features an open-port design, resulting in a higher, more consistent flow rate than single-port cutters (Figure 2) (http://www.bausch.com/our-company/recent-news/id/2408/3222018-thursday ).

Figure 2. Bi-Blade dual-port probe (Bausch + Lomb).
IMAGE COURTESY BAUSCH + LOMB

Hypervit Dual Blade

The Hypervit vitrectomy probe (Alcon) is a new cutter designed for the Constellation vitrectomy system that has a dual-blade mechanism (2 cuts per duty cycle), which reduces retinal traction. It can deliver 20,000 cpm with consistent flow rates, and it also has a beveled-tip design. It is available in 23-, 25-, and 27-gauge.

HYPERSONIC VITRECTOMY

Vitesse Hypersonic Vitrectomy

Hypersonic vitrectomy is a new concept based on a piezoelectric ultrasound transducer that liquefies the vitreous at the edge of the port. Vitesse Hypersonic Vitrectomy (Bausch + Lomb) reaches a much higher cut rate than guillotine-based cutters of ~1.7 million cpm (Figure 3). This rate does not compromise the aspiration efficacy, and its flow is consistent due to the open-port design, which is completely open at all times. Also, it produces unobstructed aspiration, which allows for the removal of vitreous, silicone oil, and soft lens material with the same probe (http://www.bausch.com/ecp/our-products/vitreoretinal-surgery/vitesse-hypersonic-vitrectomy ).

Figure 3. Vitesse hypersonic vitrectomy (Bausch + Lomb) device (A) and mechanism of action (B).

VIEWING SYSTEMS

Oculus BIOM HD Disposable Lens

The Oculus BIOM HD disposable lens (Oculus Surgical) combines an extremely wide field of view (130°) with high-definition clarity (Figure 4). It enables enhanced depth of field even under high magnification, reducing the need for a contact lens during macular work. Additionally, it provides an improved peripheral view even under air. It is compatible with all Oculus BIOM 3/4/5 products (http://www.oculussurgical.com/us/products/oculus-biom-5/disposable-lenses/ ).

Figure 4. The Oculus BIOM HD Disposable Lens (Oculus Surgical).
IMAGE COURTESY OCULUS SURGICAL

VARIOUS INSTRUMENTS

Stiffened Light Pipes With Holekamp Membrane Wipe

Available in 25- and 27-gauge light pipes, the stiffened shaft of this instrument by Katalyst makes 27-gauge as stiff as 19-gauge. It comes with a membrane wiper on the tip to remove sticky membranes from the forceps tips (Figure 5).

Figure 5. Stiffened light pipe with Holekamp membrane wiper (Katalyst).

Retractable Tissue Manipulator

Available in 23- and 25-gauge, the retractable tip of this manipulator by Vitreq is made of silicone, which facilitates insertion through the trocars, including valved trocar cannulas. Its brush tip was designed for atraumatic brushing of retinal surface. Due to its silicone tip design (without diamond fragments), there is a reduced risk of losing fragments. Also, its green tip provides a clearer distinction from the retina (http://www.vitreq.com/de/products/vitreoretinal-consumables/retractable-tissue-manipulator/25g-retractable-tissue-manipulator ).

Disposable Backflush

Available in 20-, 23-, 25-, and 27-gauge and with blunt, soft, and brush tips, the reduced size of the handle of the Disposable Backflush (DORC International) reduces interference with the BIOM. Also, it contains a larger reservoir that requires less force to be activated, resulting in greater stability (https://www.dorc.eu/product/disposable-backflush-instrument-brush-needle-and-active-aspiration23-gauge-06-mm ).

Green 38-Gauge PolyTip Cannula

The PolyTip Cannula (MedOne) is available in 23-, 25-, and 27-gauge. It is ideal for subretinal injection, with the shorter 2-mm tip length resulting in increased stiffness for easier insertion into the subretinal space and into valved cannulas. The green tip allows for enhanced visibility (Figure 6) (http://www.medone.com/products/dr_polytipcannulas.html ).

Figure 6. Green 38-gauge PolyTip Cannula (MedOne Surgical).

Maeno-Awh Super Manipulator

This instrument by Katalyst consists of a rubber sphere at the end of a soft silicone tip designed for atraumatic internal limiting membrane (ILM) flap manipulation. It was developed with a sliding T-tube technology for easy insertion into valved cannulas.

Sharkskin ILM Forceps

The Sharkskin ILM forceps (Alcon) introduce an enhanced 27-gauge grasping platform with a new technology to increase friction on the backside of the ILM forceps’ tips. Their microstructured tip improves grasping, resulting in less shredding and less need for regrasping during peeling. They were designed to facilitate initiation of ILM peeling with the reduced closing angle of platforms and increased grasping edge length (Figure 7).

Figure 7. Sharkskin ILM forceps (Alcon).

ACTU8 Disposable ILM Forceps

The ACTU8 forceps (Vortex Surgical) were designed with 8 individual levers for 360° actuation and enhanced precision control Also, they were created with a glare-free shaft and are available in 23- and 25-gauge (https://www.vortexsurgical.com/actu8-disposable-forceps ).

Morris ILM Forceps

Developed with a curved tip that enables a clear view of the forceps tips when turned over and held obliquely, the Morris ILM Forceps (Katalyst) also have a blunt tip designed to reduce the trauma at the site of contact with the retina. The forceps can be flipped over after the membrane is grasped, and its elbow can be used to hold and peel the ILM without tearing. They are available in 23- and 25-gauge (http://www.katalystsurgical.com/instruments-posterior/ophthalmic/morris-ilm-forceps ).

Morris Honey Badger Forceps

Developed for epiretinal membrane (ERM) peeling, the sharp tip of the Morris Honey Badger Forceps (Katalyst) enables a small contact point with the ERM. Also, the curved tip creates an unobstructed view of the forceps’ tip. They can be flipped over after an edge is created, and its elbow can be used to peel the ERM without tearing. They are available in 23- and 25-gauge (http://www.katalystsurgical.com/instruments/ophthalmic/dex-morris-forceps ).

27-Gauge Wide-Grip Extended-Reach Forceps

Designed with significantly increased rigidity, the strong tip of the Extended Reach Wide Grip Microforceps (DORC International) with serrations allows for stronger grip of membranes. The forceps were designed to have a 60% increase in grip width, 260% increase in grip area, and 40% increase in stiffness compared with the current 27-gauge forceps. The improved stiffness allows for 23-gauge performance with 27-gauge forceps and extended reach for more peripheral work (https://www.dorc.eu/video/new-extended-reach-wide-grip-27g-forceps-1286wrd04 ).

3D Printer Customized Retinal Forceps

The currently available forceps have a standard design that does not consider the variation in the size and shape of surgeons’ hands and grips. The 3D printing technology (David Chow/Katalyst) allows for greater product customization to accommodate the surgeons’ features and preferences (Figure 8). The mold created is printed with an SLS 3D printer, and replacement parts can be made locally.

Figure 8. Three-dimensional printed customized retinal forceps (Katalyst/David Chow) showing the differences between surgeons’ grips.

Vitreoretinal Convenience Kit

This small, compact, efficient kit from Vortex Surgical (Figure 9) combines the most frequently used disposable products: ACTU8 forceps, retractable-edge Advantage ILM elevator, soft-tip cannula, and Volk disposable flat lens. Its advantages include ordering simplification, easier set-up, lower cost, and greater possibility of customization (https://www.vortexsurgical.com/ck2 ).

Figure 9. Vitreoretinal Convenience Kit (Vortex Surgical): ACTU8 forceps, retractable edge advantage ILM elevator, soft tip cannula, and Volk disposable flat lens. Vortex Convenience Kits are fully customizable and aimed at driving operational and financial efficiency.

Treq-Blue

Treq-Blue dye (Vitreq) was developed to stain the anterior capsule for cataract surgery in those cases of reduced visualization of the rhexis rim and poor red reflex and. It consists of an ultrapurified trypan blue dye made by a 2-step purification process. The purification process decreases its toxicity and improves the staining effect. It is available ready for use with a silicone plunger and finger flanges for stable injection (http://www.vitreq.com/de/products/surgical-liquids/treq-blue/treq-blue-2 ).

LASERS

Laser Light Source

The laser-light system by Vitreq comes with 3 laser light diodes: blue (450 nm), green (520 nm), and red (638 nm). It has a higher power output capability of up to 80 lumens. Because it allows for a tunable color, the blue wavelength can be removed, thus increasing safety.

Vektor Articulated Illuminated Laser Probe

The Vektor Articulated Illuminated Laser Probe (Alcon) allows for better access to the anterior retina due to its continuously adjustable articulation.

Directional Laser Probe

Available in 23-, 25-, and 27-gauge, this probe by Vitreq was developed with a stiffened metal shaft that diminishes its flexibility by 25%. Its 90° extendable curved tip affords access to the anterior retina (Figure 10). Illuminated options are available (http://www.vitreq.com/en/products/vitreoretinal-consumables/laser-probes/ ).

Figure 10. Directional laser probe with extendable curved tip up to 90° (Vitreq).

Ngenuity With Data Fusion

The Ngenuity 3D visualization technology (Alcon) has well-known benefits that include improved depth of field, greater magnification, precise focus, increased safety due to lower light levels, and its importance in teaching. A new feature is that Ngenuity can now be integrated with the Constellation platform. The Ngenuity set-up can be customized and controlled by either the foot pedal or the touch-panel screen. It enables image mode access through the Constellation and allows the surgeon to obtain snapshots, record the procedure, and control camera orientation, among other features.

CONCLUSION

The surgical instrument arsenal is continuously increasing and evolving to improve surgical efficiency and safety. Innovations also enable the development of new techniques. The latest innovative instruments and current trends in vitreoretinal surgery include enhanced viewing systems to improve retinal visualization, high-speed cutters for diminished retinal traction, new ILM/ERM forceps and laser probes for increased precision, and custom-made kits and instruments to meet surgeons’ preferences.

Surgeons can often find it difficult to leave their comfort zone regarding surgical techniques and instrumentation. However, trying new instruments and technologies is paramount to facilitating constant development and progress in retinal surgery. RP