Laser Technology and Advanced Control

Experts explore today's instrument options and how they prefer to use them.

Dr. Charles: The PurePoint Laser is embedded in the Constellation Vision System. The new laser system incorporates a multi-function foot switch that allows the surgeon to go to standby and ready, and to adjust power settings.

One of the big problems — Murphy's Law — is that you only need a circulator when the circulator is not in the room. You have a sophisticated machine that is controlled when you talk to somebody who really has a different agenda. The circulator's jobs are patient safety, documentation and supporting the anesthesiologist or anesthetist. Who is going to run the laser? Well, it should be the surgeon. One of the additional components that makes the laser pedal work well for the standby-ready transition, as well as the laser power up and down function, is the voice confirmation feature. The advantage of voice confirmation is the ability to control laser parameters without having to look at the display or rely on the circulator.

Dr. Flynn: Another important feature of the PurePoint Laser is dual laser attachment ports. This feature allows the ease of switching to the indirect laser without additional set-up time. The PurePoint also contains the light source for the LIO. In many centers, including our own, you have to bring out a big box, unpack everything and set up the indirect laser. The functionality of the PurePoint Laser eliminates this need.

One of the additional components that makes the laser pedal work well for the standby-ready transition, as well as the laser power up and down function, is the voice confirmation feature. The advantage of voice confirmation is the ability to control laser parameters without having to look at the display or rely on the circulator. — Steve Charles, MD

LASER PROBE TECHNOLOGY

Dr. Chang: Let's discuss laser probes — what probes you are using and why you prefer them.

Dr. Charles: I use straight laser probes but I had the opportunity to test both a new flexible tip and an articulating illuminated probe. I actually like them both. Both of these probes solve two things: The first is avoidance of bumping the back of the lens. The second is what I call the "obliquity" issue. If you are trying to treat near the sclerotomies on the same side, the straight produces an elliptical beam that is hot on the near side and cold on the far side. If you get closer to the retinal surface, the remaining liquid there will form a meniscus to the tip, which will defocus the beam.

Professor Tano made the point that you do not want to go in and out with the instruments too much. This feature addresses that issue of treating both the temporal and the nasal side from one port while addressing a fair perpendicular delivery.

Dr. Packo: I have always loved curved illuminated laser probes. The curvature gives you the clearance off the lens, as was pointed out, around the curvature of the eye, and the illumination gives you the ability to scleral depress externally and not relegate that to an assistant, which adds a whole other layer of communication and reaction time problems. They cannot read your mind and subtle changes in how you are moving, so you want to do it yourself.

Professor Tano: I prefer the new flexible tip laser probe because it is surgeon-friendly. I think only a small amount of curvature is needed to cover the entire fundus. But otherwise, I think as Dr. Packo said, the curved laser is an essential tool for ordinary vitreous surgery.

Dr. Chang: Dr. Flynn?

Dr. Flynn: I agree. I generally use the retractable probe for most cases, either 23-gauge or 20-gauge. When the new articulating illuminated endolaser probe becomes available, we will all be very happy.

I also want to comment on 20-gauge surgery. One of the instruments I liked when doing 20-gauge surgery was the illuminated endolaser probe, particularly in patients with retinal detachment. With micro-incision surgery, we have not had that combination feature. But it's coming.

With the Constellation, we will have both 23- and 25-gauge articulating illuminated endolaser probes. I think that is going to be a real help for us, not only in diabetic vitrectomy, but also in the peripheral retina, where we are trying to treat peripheral retinal breaks. The view is not ideal in the periphery, and sometimes we may have some issues with a cataract or the media. But the extra light from an illuminated endolaser probe would be terrific.

I prefer the new flexible tip laser probe because it is surgeon-friendly. I think only a small amount of curvature is needed to cover the entire fundus. — Professor Yasuo Tano

COALESCENCE OF IDEAS AND CONCEPTS

Dr. Chang: Thank you all for participating in this symposium. Your ideas and expertise were very helpful. We had a very unusual experience, sampling the next generation vitreoretinal surgery system, the Constellation Vision System. A coalescence of ideas and concepts from surgeons like us, practicing in the community, have combined with a wonderful engineering team at Alcon to develop this system.

I think the consensus is that this is a significant step forward in vitreoretinal surgery. We all look forward to using it more extensively in our surgeries and to enhancing our procedures. So thank you all for coming. We look forward to hearing about your additional experiences.

Finally, I would like to add that Dr. Charles deserves the credit for many of the new developments. He has always been at the forefront of developing surgical technology and bringing it into practice. Dr. Charles, you should be very pleased with the product that was developed here.

Dr. Charles: Thank you very much. I am very excited about it. It is great to work with such super people, as you said, both the engineering team and the surgeons at this table and other surgeons that have provided input. This is a team accomplishment. To see it come to reality and to use it in the operating room last month is tremendously exciting to me. A reason to keep working for another 20 years! RP