Improving Safety, Efficacy and Productivity

As a next-generation technology, the Constellation Vision System provides the whole package.

Improving Safety, Efficacy and Productivity

As a next-generation technology, the Constellation Vision System provides the whole package.


The value of new medical technologies has always been measured by improvements in safety and efficacy. But given the realities of modern medical economics, practices and surgical centers also want to know whether purchasing a technology can make them more productive. If not, they run too big a risk that it will drain resources rather than fuel forward progress. The Constellation Vision System (Alcon) was developed from the ground up with all three metrics – safety, efficacy and productivity – in mind. The result is a “game-changing” vitreoretinal surgery platform, according to Sunil Gupta, MD, founder of the Retina Specialty Institute in Florida. Pravin U. Dugel, MD, managing partner of Retinal Consultants of Arizona, agrees. “Having been involved in the development process, I knew this system would change the way I operate,” he says. “Its predecessor, the Accurus, is a great system that I used for years. That said, the Constellation is not a better Accurus. It is an entirely different technology platform.”

The Constellation incorporates innovative features designed and integrated in such a way that a gain in safety is also a gain in efficiency and vice versa. Inside the eye, it gives the surgeon unprecedented control, while at the same time making him less reliant on multiple staff members in the OR. Outside of the eye, simplified setup and takedown saves time and allows staff members to focus on their primary roles.

Intraoperative Advantages

The Constellation is capable of an ultra-fast cut rate of 5,000 cpm. “Many other cutters are spring-driven, and the spring can’t keep up with higher cut rates, so the cutter remains closed most of the time,” Dr. Dugel explains. In contrast, the UltraVit cutter designed for the Constellation has a dual pneumatic drive, which means one line is dedicated to opening the cutter and another is dedicated to closing it. This enables the surgeon to have control of duty cycle, which is the percentage of time the cutter remains open in a given cut cycle, independent of vacuum and cutting rate. Based on the surgical goal, one of three duty cycles can be used: port biased open, port biased closed or 50/50. “This is an impressive example of how the Constellation marries safety and efficiency,” Dr. Dugel says. “For instance, the port biased open setting allows significantly faster removal of core vitreous. This means we are in the eye for less time, which creates a better experience for the patient. Postoperatively, the eye is quieter and recovers faster. Using the port biased closed setting allows the shaving of peripheral vitreous on the retinal surface to be accomplished with a significantly higher margin of safety.”

As duty cycle control, ultra-high cut rate and vacuum level control how vitreous is removed from the eye, the IOP Compensation feature of the Constellation controls how fluid enters the eye. The system continually monitors infusion pressure and other relevant factors, such as tubing resistance, and makes real-time adjustments so intraocular pressure is maintained at set levels throughout surgery. “This is as accurate an IOP as you can get, which is a major contributor to the exceptional fluidics and globe stability provided by the Constellation,” Dr. Dugel says.

The advantages of the high-performance cutter, duty cycle and IOP control are evident no matter what gauge instrumentation the surgeon chooses to utilize, Dr. Dugel says. He prefers the 25+ gauge tools designed for the Constellation. The 25+-gauge UltraVit probe has a larger internal lumen and a larger port closer to the tip than other 25-gauge probes. Dr. Gupta describes the benefits, saying “With duty cycle control and this probe design, I can work right on the surface of the retina with minimal traction. Furthermore, the probe is a multifunctional tool. I can use it like a pick or forceps, for example, which significantly reduces the number of times I have to move in and out of the eye to exchange instruments. Even in severe cases of diabetic eye disease, I can’t remember the last time I had to open a pair of scissors to dissect scar tissue.”

Checks and Balances with Streamlined Workflow

Dr. Gupta says he also appreciates the Constellation Vision System’s integrated xenon illumination and 532-nm green laser. “Instead of a separate illumination unit sitting on top of the vitrectomy machine and a separate laser cart, cables, knobs and display, we can control everything from the Constellation screen,” he says. When the surgical pack is scanned, the system is automatically set up for the appropriate port size functionality. For added safety and efficiency, the illuminator and laser as well as all system accessories work with Radio Frequency Identification Device (RFID) technology. RFID automatically recognizes each device being connected and adjusts key parameters, such as light intensity. If anything is plugged into the wrong spot, the LED light around the port turns red to indicate a mistake.

“ The advantages of the high-performance cutter and duty cycle and IOP control are evident no matter what gauge instrumentation the surgeon chooses to utilize. ”

— Pravin Dugel, MD, Managing partner of Retinal Consultants of Arizona

Additional checks and balances include automatic calculation of fluid use. “The system issues a warning when the infusion bottle is becoming depleted,” Dr. Gupta explains. “A reservoir provides some additional fluid so air doesn’t get into the line, and a second warning that the bottle needs to be changed is triggered. Furthermore, it can be changed without stopping, plugging and clamping.” With the Constellation, it’s also possible for the surgeon to activate an air-fluid exchange, by either pressing a button on the screen display or using the foot pedal.

The surgeon can also use the foot pedal to increase or decrease laser power or to adjust IOP. “It makes much more sense for the surgeon to have the ability to control a variety of functions with the foot pedal, rather than to wait for a nurse to assist,” Dr. Dugel says. The streamlined operation and setup of the Constellation overall means fewer staff members are needed before and during each case. “Because of features like push priming, automatic gas fill and RFID, a scrub tech alone can set up the machine and handle turnover between cases,” Dr. Dugel says. “That means other staff members, such as nurses, can focus their time and expertise where it is meant to be focused.”

Net Gains in Productivity

Drs. Gupta and Dugel have experienced firsthand how the intraoperative and perioperative efficiencies made possible by the advanced features of the Constellation can have a positive impact on a practice beyond improved safety and efficacy. The system has allowed Dr. Gupta to complete cases in 25% less time. He recently had the opportunity to test the new cutter that is being developed for the system. “The next-generation pneumatically driven cutter allows for a true 7,500 cuts per minute,” he says. “I truly think it will represent another significant step forward in safety and efficacy.”

Dr. Gupta has also evaluated the impact of the Constellation being designed primarily around disposables. “There is an associated cost, but the same is true with reusables because you have to factor in the cost of labor for cleaning,” he says. “Also, even microsurgical instruments designed to be reusable are delicate. When they become damaged, they are expensive to replace. With disposables, we have no issues with sterility, a reduced risk of exposure to atypical-disease-causing prions, and we know the instruments are going to work every time because they are brand new.”

An independent study at Dr. Dugel’s practice, conducted by Quorum Consulting of San Francisco, Calif., and funded by a grant from Alcon, revealed several positive economic dynamics related to upgrading from the Accurus to the Constellation. The study was done with an activity-based costing (ABC) methodology. Rather than focusing on the traditional concepts of fixed and variable and direct and indirect costs, ABC focuses on where the activities of the practice are centered. It allocates expenses to the activities, which is designed to provide a more accurate picture of not only revenue but also expenses and profitability. In the Dugel study, the methodology was used to compare 6 months of surgeries performed with the Accurus with 6 months of surgeries performed with the Constellation. The results showed that the practice profit margin was 57% higher when the Constellation was used. On a per-case basis, although the Constellation was more expensive, it was more cost-effective (and ultimately more profitable) than the Accurus.

According to claims data, while the number of retina surgery days decreased as a result of acquiring the Constellation, the total number of patients, number of patients per day, total allowed payments, allowed payments per day, and average allowed payment per staff hour all increased. Based on employee time-card data, due to increased patient volume, the average number of staff hours worked per day, average number of staff working per day, and registered nurse hours per day all increased. However, the overall number of overtime hours decreased by almost 100%. “Before acquiring the Constellation, we had been logging a significant amount of overtime from nursing staff,” Dr. Dugel says. “To achieve the best OR turnover times with the Accurus, nurses had been working alongside scrub techs during setup and takedown. As such, they weren’t able to complete their procedure reports until the surgery day was done. They might have 15-18 reports to complete after I left. Now they can work on reports between cases, and we really have no overtime for paperwork anymore, which is a significant cost savings.”

For Dr. Dugel, the take-home point of the study was “while excellence in patient care is always our top concern, we see that by analyzing not just the capital expense of new equipment but also the return on investment, it is possible to have both better care and improved productivity, which ultimately leads to better profitability.” ●