Alcon, a division of Novartis, offers the Finesse Sharkskin ILM Forceps, which increases surgical precision to enhance retinal surgery outcomes. The forceps has a large grasping platform and a texturized tip surface, which enables surgeons to more easily grasp and peel the internal limited membrane (ILM) and minimize membrane shredding that can be caused by multiple grasping attempts.
Paul Hallen, global head of surgical retina and glaucoma at Alcon, explains that the laser-ablated microstructures on the tip surface — which resemble a shark’s textured skin — increase friction between tissue and the forceps to improve grip during ILM peeling. Hallen says sharks have placoid scales comprised of a matrix of tiny, hard, tooth-like structures with an enamel-like covering. These structures make the skin a very tough armor with a texture like sandpaper. Like shark skin, the forceps has textured tips.
Firas M. Rahhal, MD, a partner at Retina Vitreous Associates and an associate clinical professor of ophthalmology at UCLA School of Medicine, both in Los Angeles, California, wanted to try the forceps because, “The idea of grasping ILM more easily without having to create as much indentation force or physical trauma when grasping very fine membranes on the retina’s surface or inner retina, was attractive.” He added that the proposed advantages panned out in actual practice.
Hallen says vitreoretinal surgeons have cited 2 main challenges with other forceps. Most surgeons initiate ILM peeling by “pinch peeling.”
“They use forceps to directly grasp a section of ILM, lift it from the retinal surface to initiate a tear, and then start peeling,” Hallen says. “To initially engage the ILM, the surgeon has to push the open forceps into the retina by a few microns and then close the tips to grasp the ILM, hoping to avoid inadvertent retinal trauma. The amount of force applied to do this optimally is difficult to judge. By increasing friction between the instrument and ILM, the intent is to reduce the need for this normal force on the retina during procedures, which can result in unnecessary trauma.” He added that this innovative forceps is designed to mitigate both the challenge of judging necessary force and the risk of injury to the retina.
Steve Charles, MD, FACS, FICS, CEO and founder of Charles Retina Institute, and clinical professor of ophthalmology at the University of Tennessee, both in Germantown, Tennessee, can attest to these benefits. “By minimizing the need to regrasp as a result of the microtextured contact surface, the chance of retinal damage due to shredding decreases,” he says. “The grasping platform has a longer circumference and therefore less force per unit area.”
DIFFERENT SIZE OPTIONS
Indications for ILM peeling include macular hole, epiretinal membrane, vitreomacular traction syndrome, vitreomacular schisis and myopic foveoschisis, and proliferative vitreoretinopathy. To address surgeons’ varying preferences, the forceps comes in 23, 25+, and 27+ gauges. The 27+ forceps has been developed with an enlarged grasping platform, with the area almost equal to that of the 25+ gauge forceps. “It is 59% larger than the prior 27-gauge platform, and therefore proportionately reduces pressure on the membrane and minimizes the likelihood of it being shredded by excessive pressure,” Hallen explains.
The 27+ forceps features the same conformal grasping platform as the 23 and 25+ gauge versions, with a more rectangular shape. “This may reduce the risk of pinching into the sensory retina with the edge of the grasping platform when grasping in an angled configuration,” Hallen says.
The strong, carefully engineered forceps is intended to provide added protection to the underlying retina during peeling, Hallen says. By increasing dynamic friction, a reduced normal force on the patient’s macula may result in reduced trauma.
It is advantageous that the microinstrument is single use. “Cleaning can gradually damage fine tips,” Dr. Rahhal says. “Because the forceps is disposable, I have a brand new, perfect tip every time I perform retinal surgery.” He believes the forceps is more cost effective because it doesn’t need to be cleaned or cared for, and repairs aren’t necessary.
Dr. Rahhal says the forceps functions like typical forceps, so there’s no learning curve. By requiring less indentation force, surgeons have less fear of traumatizing the delicate retina. “The forceps improve efficacy, and allow surgeons to finish that part of the procedure more quickly and with a higher frequency of complete and continuous ILM removal,” he says.
Because of the forceps’ rounded conformal leading edge, less shredding is likely to occur, Dr. Charles says, decreasing the chance of retinal damage which can result in reduced visual performance in a patient’s central vision.
In cases where the ILM is more difficult to peel, Dr. Rahhal says the forceps has allowed him to get a better grasp of the tissue, thus enabling him to complete cases. “Although the success rate for ILM peels was high before, it is even higher when using these forceps,” he concludes. RP