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Advances in High-speed Cutting

The ULTRAVIT^® High Speed vitrectomy probe puts more control in your hands for improved efficiency and control.

Expectations are high when a new or improved surgical instrument is introduced, but sometimes, it’s what the instrument does not do that impresses a retina surgeon. That was the case when Firas M. Rahhal, MD, Los Angeles, began using the ULTRAVIT^® ultra high speed vitrectomy probe about a year ago.

“To be totally frank, what first captured my attention during discussions of the ULTRAVIT^® High speed cutter was that it was reported to not have some of the disadvantages often associated with high-speed cutting,” Dr. Rahhal says. “For example, I was concerned that the higher cut rate would cause a decrease in the functional power of the vacuum to remove vitreous and, thus, would slow the case. My first cases using the ULTRAVIT^® High Speed cutter were retinal detachment repairs, and I found I could efficiently remove the vitreous at a good pace without creating any or very little traction on the retina. The retina stayed put while I was removing the vitreous. That one advantage was noticeable rather quickly.”

According to Philadelphia retina specialist Allen C. Ho, “Using very high cut rates in retinal detachment cases enables us to work close to the retina, taking little bites of the vitreous gel with less traction on the retina. When the retina is mobile, having control over what tissue comes into the port is critical. In fact, the main advantage of the ULTRAVIT^® high speed cutter is that it gives the surgeon greater control in various clinical scenarios.”

In this article, Dr. Ho and Dr. Rahhal discuss the functionality of the ULTRAVIT^® ultra high-speed cutter and its impact on efficiency and surgeon control in the operating room.

CONTROLLING FLUIDICS AND CUT SPEED

The ULTRAVIT^® probe allows the surgeon to modify the duty cycle — the percentage of time the port is open versus closed — for flow control independent of vacuum and cut rate. This is in contrast to spring-driven probes that have duty-cycle limitations at high cut speeds, causing flow limitations.

“With the dual pneumatic drive, we can control the speed at which the guillotine cutter opens,” Dr. Ho says. “By creating a more open duty cycle, we can be more efficient in removing vitreous gel. Conversely, if the mouth of the cutter is closed for most of the cycle, we can limit the amount of tissue we draw up into the cutter, giving us finer control. It’s like nibbling versus taking larger bites.

According to Dr. Rahhal, “The early iterations of vitrectomy probes with high cutting speeds were fairly safe when we were operating close to the retina, but they weren’t necessarily efficient in removing dense blood away from the retina because the flow became so low. With the fluidics of this instrument, I don’t lose the functional power of the vacuum by increasing the cut rate. I’ve found it’s efficient even when I’m working away from the retina and just removing vitreous or vitreous hemorrhage.

The combined features that enhance the surgeon’s control are designed to provide enhanced protection for the patient. “I want to be able to remove the tissue at the mouth of the cutter with as little effect as possible on anything nearby,” Dr. Rahhal says. “That level of control is one of the excellent points about this cutter. Its utility is exceptional in those spaces where we have historically used manual instruments for peeling and separating, maneuvers that are technically challenging and slow.” The probe can now be used as a multifunctional tool.

COMPLEX CASES

Both surgeons note the versatility of the ULTRAVIT^® probe is especially important in complex cases. “In cases of diabetic tractional retinal detachment where there are tissue planes that I would like to separate, the high-speed cutting allows me to do this as well, because I can nibble at high speeds or I can take larger bites with control at lower cut rates,” Dr. Ho says.

Dr. Rahhal adds, “Being able to use a cutter along the surface of the retina, removing abnormal tissue and membrane while not disturbing the retina is critical. The higher the cut rate, the more effectively that can be done.”

Dr. Ho notes, “Another clinical scenario where the high-speed cutter excels is for shaving the vitreous base. With the ULTRAVIT^® cutter, I can maintain control very close to the retina.”

EVOLVING TECHNIQUE

According to Dr. Rahhal, each advancement in vitrectomy probes — particularly from 2,500 cpm to 5,000 cpm to 7,500 cpm — has marked increased efficiency coupled with decreases in iatrogenic tears.¹ “With the high-speed ULTRAVIT^® probe, I can continue to dissect and remove pathologic tissue in very narrow spaces. Over time, I’m doing less with picks, scissors and special hand-held tools and more with the cutter itself.”

“The continued evolution of surgical instrumentation and technology for the retina surgeon allows us to do things more easily in the back of the eye, to achieve surgical goals more easily,” Dr. Ho says. “Any time things are made easier for a surgeon, that potentially translates into better outcomes for patients.”

CONCLUSION

“Sometimes, when new technology is introduced, we are skeptical,” Dr. Rahhal says. “We wonder if we really need to increase our costs and buy an additional device or another tool for the operating room. I agree with that frugality, but what we have found — and I think most physicians would agree — is that once we start using the new technologies, we almost inevitably look back over time and find that it became standard of care. This is how I view the new ULTRAVIT^® High Speed cutter.”

Dr. Ho concludes, “I would encourage surgeons to try this new technology to determine if they feel there are surgical benefits for them individually in the operating room as we try to do the best we can for our patients.”

Dr. Ho is a paid consultant of Alcon.
Dr. Rahhal is a paid consultant of Alcon.

MIVS Important Product Information

Caution: Federal law restricts this device to sale by, or on the order of, a physician.

Indications for Use: The CONSTELLATION^® Vision System is an ophthalmic microsurgical system that is indicated for both anterior segment (i.e., phacoemulsification and removal of cataracts) and posterior segment (i.e., vitreoretinal) ophthalmic surgery.

The ULTRAVIT^® Vitrectomy Probe is indicated for vitreous cutting and aspiration, membrane cutting and aspiration, dissection of tissue and lens removal. The valved entry system is indicated for scleral incision, canulae for posterior instrument access and venting of valved cannulae. The infusion cannula is indicated for posterior segment infusion of liquid or gas.

Warnings and Precautions:

• The infusion cannula is contraindicated for use of oil infusion.

• Attach only Alcon supplied products to console and cassette luer fittings. Improper usage or assembly could result in a potentially hazardous condition for the patient. Mismatch of surgical components and use of settings not specifically adjusted for a particular combination of surgical components may affect system performance and create a patient hazard. Do not connect surgical components to the patient’s intravenous connections.

• Each surgical equipment/component combination may require specific surgical setting adjustments. Ensure that appropriate system settings are used with each product combination. Prior to initial use, contact your Alcon sales representative for in-service information.

• Care should be taken when inserting sharp instruments through the valve of the Valved Trocar Cannula. Cutting instrument such as vitreous cutters should not be actuated during insertion or removal to avoid cutting the valve membrane. Use the Valved Cannula Vent to vent fluids or gases as needed during injection of viscous oils or heavy liquids.

• Visually confirm that adequate air and liquid infusion flow occurs prior to attachment of infusion cannula to the eye.

• Ensure proper placement of trocar cannulas to prevent sub-retinal infusion.

• Leaking sclerotomies may lead to post operative hypotony.

• Vitreous traction has been known to create retinal tears and retinal detachments.

• Minimize light intensity and duration of exposure to the retina to reduce the risk of retinal photic injury.

ATTENTION: Please refer to the CONSTELLATION^® Vision System Operators Manual for a complete listing of indications, warnings and precautions.

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