Elegant Surgery Without Costly Extras

Stellaris PC combines the highest cutting speeds for vitreoretinal procedures with efficiency and cost-effectiveness.

Dr. Heier: Among the significant advances in vitreoretinal surgical capabilities that have emerged in recent years, the steady improvement in vitrectomy machines has stood out. As many of us remember, we saw a big jump in cutting speed roughly 10 years ago. At that time, we went from 750 cuts per minute (cpm) to higher than 1000, which really led to increased safety and, we believe, improved outcomes.

Subsequently, the cut rates we could achieve doubled, leading to even greater comfort in vitrectomy techniques. I think many of us believed then that we had really reached the height of cut rate vs. flow, and no further increase would yield meaningful results. However, as we will discuss here, we now have instruments that allow us to operate at 5000 cpm, and that rate is coupled with significantly improved flow dynamics. So again we are asking ourselves whether this makes a significant clinical difference.

Dr. Antoszyk: Clearly, the ability to cut at a higher rate, especially with an increased duration of the open component of the duty cycle, allows us to work closer to the retina without risking the retina being incarcerated into the cutter. This facilitates shaving the vitreous base, particularly in the highly mobile detached retina.

Dr. Heier: I agree completely. I have to say when I first thought about the usefulness of higher cutting speed, I really did not think it was going to make a significant difference. However, when I tried the new vitrectors with higher cut rates, I was impressed with the stability of bullous peripheral retina when I ventured near it during procedures. It was obvious that I actually had to go up and engage the vitreous to really aspirate it into the cutter, and very little movement of the retina would occur. The movement in fact was much less than I had been accustomed to with 2500-cpm vitrectors. I do a lot of work with Fellows, and in those cases that type of stability makes a huge difference.

Dr. Wald: Usually when I am doing the vitreous shaving, I have perfluorocarbon liquid in the eye, and retina mobility is not generally that big an issue. Do you find you do not need perfluorocarbon to the extent you did before, just because the retina is already not moving very much with the 5000 cpm rate?

Dr. Heier: We are in an ASC, so we use perfluorocarbon only when we absolutely need it. I only use it in cases of severe proliferative vitreoretinopathy (PVR) and situations like giant retinal tears where retina slippage is an issue.

Dr. Blinder: I completely agree. Working in an ambulatory surgery center, we are very limited in our use of perfluorocarbon liquids, and I have not really had any complications directly related to making a posterior drainage retinotomy.

Dr. Kunimoto: As long as a complete posterior vitreous detachment is created or confirmed, I have not seen any complications with a posterior drainage retinotomy. In cases where I do not want to use that approach I just drain from the peripheral break. It may take longer to drain subretinal fluid, but with lower vacuum and directed placement of the soft tip cannula, most subretinal fluid can be drained.

Dr. Tewari: I use posterior drainage retinotomies routinely and like to see the retina flat at the conclusion of the case. Removing all of the fluid can also minimize the risk of macular folds postoperatively.

USER-FRIENDLY SETUP AND OPERATION

Dr. Heier: As you look at the new surgical technology that is available, what features are most important to you when you are looking for a system?

Dr. Antoszyk: What struck me the most when I first saw the Stellaris PC (Procedural Choice) Vision Enhancement System (Bausch + Lomb) was the simplicity of the initial screen for selecting the various components for the vitrectomy. This was dramatically displayed in the OR when after only one case, the technicians were able to easily navigate their way through the entire set-up process. It took less than 3 or 4 minutes, which in hospitals and ASCs is highly efficacious.

Dr. Wald: I agree with you on that. When you have different people setting up a surgery system and they can learn it quickly, it is an advantage. The Stellaris PC interface is truly user-friendly. All of the components are simple, too. It is even easy to program the system.

Dr. Blinder: I agree. The ease of use in setting up is extremely important. Also, we all like our “toys,” and we all want to strive for the latest and greatest technologies. However, as we mentioned, in our present healthcare system, we have to be cost-conscious. Especially for ASCs, the cost of the packs is extremely important. I think too many bells and whistles leads to higher costs. The Stellaris PC meets our demands. It is a middle-of-the-road machine (in terms of cost) that does what we want it to do. It has the technology for higher cut rates and yet a limit on the nonessential “bells and whistles” with an affordable pack price.

TWO OPTIONS FOR CONTROLLING INFUSION PRESSURE

Dr. Wald: I like having two options for infusion pressure. With the Stellaris PC, we can use a forced gas system like the Accurus Surgical System (Alcon), or we can program the foot pedal to raise and lower the bottle height, which winds up using less tubing and costing less.

In the distant past, for example, if bleeding occurred, I would have the circulating nurse raise the bottle. Now I use the foot pedal to do it. I did this with the Millennium Microsurgical System (Bausch + Lomb) too. For instance, when I am coming out of the eye, I will lower the bottle. If I am doing a fragmatome lensectomy, then I will raise it. If I am putting perfluorocarbon in, I will lower it quite a bit. So we can use numerous bottle heights with the option to have infinite levels of infusion pressure. At the same time, it is less expensive to do it that way than with a forced gas system. Although the Stellaris PC, as I said, supports that as well.

Dr. Heier: Yes, I really like having control to completely shut off the infusion pressure. I do not have to rely on a circulator when I am going through certain steps such as putting in dyes or steroids or subretinal tissue plasminogen activator.

Dr. Wald: I use this frequently. I am constantly up and down on the foot pedal. If I am suturing in a lens, for example, I want the infusion to be just at the height of the patient. I do not want much pressure, but I do not want the eye hypotonous either. At the other extreme, if I am about to cut neovascular membrane, I may want to raise the bottle. The only aspect of the Stellaris PC that is different from the Millennium that I do not like is the bottle right now moves in increments of about 15 cm. I have to keep pressing the foot pedal and it feels somewhat ratchety. However, I believe this is programmable and can be overcome.

Dr. Tewari: Being able to turn the infusion on and off is also beneficial while performing membrane peels with triamcinolone assistance. Often, when triamcinolone is placed on the retina while the infusion is on, the triamcinolone gets blown off by the force of the infusion. It is helpful have the ability to turn the infusion off as I'm putting in the triamcinolone so it stays on the retina, especially in vitrectomized eyes.

Dr. Heier: Absolutely. I know we all appreciate the Blue Tooth pedal, too. Not having the wires around is quite nice.

VITRECOMY AND PHACO IN ONE SYSTEM PROVIDES PRACTICE-WIDE BENEFITS

Dr. Heier: Do any of you feel it is important to have both vitrectomy and phacoemulsification capabilities in the same machine?

Dr. Antoszyk: Absolutely. I do not do cataract surgery myself as far as the anterior segment approach. I only do it if I have to in retina cases. However, if I am doing a combined procedure with one of my anterior segment colleagues, it is nice not to have to roll another machine into the OR, which is already a crowded space. Our anterior segment people are very comfortable using this type of platform with its fragmentation component and its aspiration capacity.

Dr. Kunimoto: I agree. I often perform combined cases with anterior segment colleagues, and our surgery center happens to be space-constrained. So having this single unit, which has a very small footprint, is a benefit. The footprint is 18 x 18 inches, so it is roughly the size of an additional standing adult in the room. Also, having the same machine for anterior and posterior procedures makes things flow much more efficiently for surgeons and technicians with setup time, swapping between anterior and posterior portions of the case, learning curve, and so on. It also saves cost in combo cases by using a single surgical pack.

Dr. Heier: We consider the dual capability a huge advantage. My feeling is I can do cataracts, but I have 15 partners who do them better than I do, so I prefer them doing it. Our surgery center is downstairs from our clinic, so if somebody needs a posterior segment surgeon, they just call us and we can go right down. Prior to acquiring the Stellaris PC, they would have to move their machine out of the way, we would move our machine in, and the turnover from anterior to posterior segment surgeon was a little bit of an issue. RP