System Enables Today's Most Advanced Techniques

The Stellaris PC is a more intuitive, compact system—ideal for both the ASC and hospital OR.

By Carl C. Awh, MD

About 5 years ago, Bausch + Lomb engaged a group of vitreoretinal specialists in its effort to design a next-generation surgical system. “What could replace the company's Millennium Microsurgical System? What did we need?” Initially, we responded with a lengthy wish list. We wanted a state-of-the-art cutter and illuminator. We wanted better control of the machine, and we wanted set up to be simpler. Our wish list even called for the machine to be fully automated and voice-controlled, with the ability to integrate with electronic medical records, play mp3 music files and edit video.

However, as we looked into the future, we recognized the global nature of vitreoretinal surgery. We came to understand that a new system should be usable throughout the world to perform both anterior and posterior procedures. We considered the migration of retina cases to ambulatory surgical centers taking place in the United States. We also recognized that we didn't fully understand how changes in national healthcare policy might affect what is important to us financially in the operating room. So we decided to revise our list of wishes. Some of the features we thought would be interesting to have were not really necessary for doing a great job for our patients. Our goal was not to have the most expensive or elaborate system, but to have an elegant system that does the job well.

The culmination of our collaboration with Bausch + Lomb is the Stellaris PC (Procedural Choice) Vision Enhancement System—a true dual-function platform. The Stellaris has been the premier cataract surgical system from Bausch + Lomb, enabling sub-2-mm phaco and IOL implantation. Now, we have that anterior segment function combined with state-of-the-art vitrectomy performance. The Stellaris PC features plenty of next-generation technology, the most important being an ultra-high-speed cutter and a brighter and safer light source. In addition, it's a very compact and user-friendly machine. Notably, it has an open architecture, meaning we can use any accessories and disposables we want, even if they're not sold by Bausch + Lomb. While this may not be ideal for the company, we as surgeons know we have our preferred tools and we want to be able to use them without limitations.

The Stellaris PC became available to U.S. surgeons in August 2010. At the time of this writing, my staff and I had used the system for 4 days and we were extremely pleased with our first impressions.

WIRELESS PROGRAMMABLE FOOT PEDAL

One of the features of the Stellaris PC, and a nice example of the thought that has gone into the design of this device, is the wireless foot pedal. Our staff loves that they no longer have to stoop around the foot of the operating table to drag or position a cable. I like the programmable aspect of this pedal. It can be programmed to control any of a long list of functions using the four auxiliary buttons on the pedal. Each surgeon's preferred settings are stored in memory and retrieved when the machine is activated.

Like its predecessor, the new foot pedal allows dual linear control. The ability to independently vary vacuum and cut rate, or vacuum and phaco power, is a capability I valued with the Millennium, and I'm pleased it has been maintained for the Stellaris PC.

USER-FRIENDLY, INTUITIVE INTERFACE

The user interface on the Stellaris PC eliminates the need to navigate through layers in order to control the various functions. When the machine is in vitrectomy mode, everything needed to control the vitrectomy is on that panel. When the machine is switched to phaco mode, a different panel appears—again, with no need to go through sublevels. There is even a screen for combined phaco-vitrectomy cases.

The screen is intuitive and light-adapting. It puts itself in a darker mode when we're performing a vitrectomy. It also has a useful swivel feature, which means we don't have to move the entire machine around if I want to look at the screen from a different angle.

EFFICIENT SETUP

The system is easy to set up. The packs are transparent and color-coded, and when our scrub techs open them, all of the elements can be quickly and efficiently plugged in. It's even more appealing and time-saving that the system primes itself. The surgical tech pushes one button and can walk away to tend to other tasks while the Stellaris PC auto-flushes the cutter, infusion, and extrusion lines and tests the cutter. The whole process takes less than a minute, and we're ready to perform surgery.

THE STELLARIS PC IN ACTION

One of my first cases with the Stellaris PC was a traction detachment beginning to involve the macula in the only seeing eye of a young patient with poorly controlled diabetes. Because of the open architecture, I was able to use my preferred chandelier light, which is not a Bausch + Lomb product. I used the chandelier with the Stellaris PC Mercury-vapor light source set at 100%, together with a standard light pipe in the Stellaris PC xenon light source set at 50%. To have two types of light sources, each filtered to minimize phototoxicity hazard, is a great advantage. The switchable integrated color filters, controlled from both the footpedal and the touchscreen, should prove to be a useful visualization enhancer.

The surface area of the port of the 25-gauge Stellaris PC cutter is relatively large and the port has been moved down closer to the end of the probe, which improves functionality. In this case, with the cutter set for 5000 cpm, I was able to trim fibrovascular pegs and “shave” fibrous membranes from the somewhat atrophic retinal surface, without any detectable traction.

I also used the system's reflux feature, which is designed to help identify small bleeders and can be set at two different levels of reflux. This is particularly helpful if I need diathermy in my fellow hand, which is a useful bimanual technique enabled by chandelier illumination. After removing the light pipe from the eye, I began to bimanually dissect the thickest area of plaque over an area of thin and tractionally elevated retina. Using just the 25-gauge cutter and a serrated pick in my fellow hand, I was able to completely dissect the membranes without creating any retinal breaks.

The sleek design of the Stellaris PC (Procedural Choice) offers a small footprint, just 18 × 18.

I then stripped the internal limiting membrane from over the slightly edematous macula, added endolaser panretinal photocoagulation and performed a fluid-air exchange. Although there were no retinal breaks, I wanted the bubble to tamponade the macula and to help reattach the area previously under traction.

As usual, the transconjunctival wounds created with 25-gauge vitrectomy looked excellent at the conclusion of surgery and the patient was comfortable and had a normal intraocular pressure on the first post-operative day.

During my first day with the new system, I also performed four other procedures. I was pleased with the results in all four cases and, equally important, my staff was enthusiastic about their first experiences with Stellaris PC.

VERSATILITY ADDS VALUE

As previously mentioned, the Stellaris PC is a true dual-function retina and cataract platform. This extends all the way through to the packs that are available. For example, vitreoretinal surgeons who perform combined procedures can use just one pack for both phaco and vitrectomy, moving seamlessly from one mode to the other.

The versatility of the new system—along with its ultra-high-speed vitreous cutter, brighter and safer dual light source, compact size, user friendliness and open architecture—makes it quite valuable to today's surgeons. Bausch + Lomb has been a consistent innovator in our field, from the introduction of the first Microvit probes through the development of transconjunctival sutureless vitrectomy. With the development of the Stellaris PC, we have a next-generation system to help us provide the best care for patients while continuing to advance our field.

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Dr. Awh, an internationally recognized clinician, surgeon and educator, practices at Tennessee Retina in Nashville.

Stellaris PC Q&A

Q: I've been a Millennium user for the past several years, and I've noticed that during cataract surgery, when I take my foot off the pedal, the vacuum doesn't cut off immediately. Sometimes this causes aspiration of the iris tissue into the port until I just stop there and the iris retracts. Is the Venturi system on the Stellaris PC going to be an improvement in this area? Dr. Awh: That is not so much a Venturi issue but is due to the fact that in the Millennium, when you go to zero, the aspiration line is still vented. Therefore, you may get some passive aspiration. With both the Stellaris and the Stellaris PC, that problem does not exist. Both systems have a pinch valve so that when you come off the foot pedal, there's no venting at all. Q: Some surgeons have talked about the importance of limiting flow. How do you juxtapose that with a duty cycle that favors an open position? Dr. Awh: If we have our foot off the pedal and our port is 100% open, we have zero flow. A duty cycle biased toward an open position certainly allows outstanding flow, but still allows us to use extremely low flow when needed. Flow is controlled with aspiration; therefore, with very low levels of aspiration, we have very low levels of flow, particularly at 5000 cuts per minute. So there's really no need to manipulate the duty cycle. It's certainly true that another way to reduce flow is to modify the duty cycle so that the port is barely open at all. However, reducing duty cycle doesn't reduce the size of the port, only the percentage of time the port is open. With a 5000 cpm cutter, this is unnecessary—we have complete control of flow simply by varying vacuum.”