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Conquering Small Spaces

The 27+^® Portfolio gives you the tools you need for successful microincision vitrectomy surgery.

For vitreoretinal surgeons, space — in the back of the eye, that is — may, indeed, be the final frontier, as new fine-gauge instrumentation provides access to small tissue planes. To that end, Alcon recently introduced its 27+^® Portfolio, the latest innovation in the CONSTELLATION^® Vision System. We asked 2 distinguished surgeons for their first impressions.

INSTRUMENT RIGIDITY

As proponents of microincision vitrectomy surgery (MIVS), both Homayoun Tabandeh, MD, Los Angeles, and Steve Charles, MD, Memphis, Tenn., agree: The smaller the wound, the better.

“Step-by-step, vitrectomy surgery is becoming less invasive,” Dr. Tabandeh says. “MIVS has had a major impact on the outcomes and morbidity of vitreoretinal surgery, and the 27-gauge system further expands the frontiers of microsurgery for retinal diseases. A clear advantage of 27-gauge MIVS is that it is less traumatic to the eye.”

One concern, however, is that the smaller the gauge, the more flexible an instrument may be, which can limit its utility. “As we move to increasingly smaller gauge systems, the question arises: What are the surgical maneuvers or procedures that we may not be able to perform with these systems?” Dr. Tabandeh says. “I was most impressed with the rigidity of the ULTRAVIT^® 27+^® probe. I had expected it to be more flexible, but the stiffness appears similar to that of the 25+^® probe.^1,2 This allows for excellent control of the instruments. In addition, the small size of the vitrectomy probe allows access to tight surgical planes.”

The dual actuation of the ULTRAVIT^® 27+^® vitrectomy probe facilitates ultra-high speed cutting performance up to 7,500 cuts per minute (cpm). The 1-mm stepped stiffening sleeve enters the cannula for maximum working length, and the full 27-mm shaft length is equal to the 25+ probe.

According to Dr. Tabandeh, the ULTRAVIT^® 27+^® vitrectomy probe allows for efficient removal of vitreous, with minimal movement of vitreous during cutting.³ “The instrument is rigid enough to allow surgical manipulations and removal of peripheral vitreous,” he says. “The ULTRAVIT^® 27+^® vitrector aspirates efficiently and can effectively handle difficult maneuvers, such as engagement and stripping of the posterior hyaloid face.”

The 27+^® Portfolio includes the 27+^® EDGEPLUS^® Valved Cannula, which easily disengages from the trocar after insertion without a secondary instrument. A vent is provided for cases that require normalizing pressure with silicone oil or perfluorocarbon liquid. “The 27-gauge infusion cannula appears to keep up with the demands of 27-gauge as well as 25-gauge instruments, maintaining the intraocular pressure effectively,” Dr. Tabandeh notes. “Availability of a wide range of secondary intraocular instruments allows the 27+^® system to be used for complex vitreoretinal procedures.”

EXCELLENT FLUIDICS

Dr. Charles, a retina specialist who is also an electrical engineer and a mechanical engineer, is the principal architect of the ACCURUS^® and CONSTELLATION^® vision systems. He describes the fluidics of the ULTRAVIT 27+ system as “terrific,” and goes on to explain why.

“The CONSTELLATION^® Vision System has dual actuation, meaning the cutter is actuated on the downstroke and the upstroke, with 2 valves and 2 tubing connections driving it,” he says. “That means the flow rates do not decrease at high cut rates.³ Why does that matter in the context of 27-gauge? Resistance to a fluid flowing through a pipe is proportional to the fourth power of the diameter, so going from 25-gauge to 27-gauge can have a significant impact in terms of limiting flow. If a cutting speed of 7,500 cpm were to further limit flow, that would be a problem. In fact, Alcon’s ULTRAVIT 7,500 cpm probe does not limit flow. It has more flow because the pulses of fluid that go through the port at each open and close cycle remain the same.³ If you do more of them in a given time interval, you get more flow. In short, in a way, the cut rate of 7,500 cpm compensates for the slight flow reduction of the 27-gauge system.”

Dr. Charles recently put the 27+ system to the test in his OR. “I was interested to see if I could operate on tough cases in a reasonable time with 27+, and it was an absolutely banner day,” he says. “I was delighted that I could repair the toughest diabetic traction retinal detachments. The scissors work well, and the MAXGRIP^® forceps work well to peel thick diabetic epiretinal membrane from the disk. The ILM forceps work very well for the macular surgery cases, and the fluidics were great. I performed a successful silicone reoperation with retinectomy without removing the silicone oil from the eye. In short, I found the 27+ to be terrific.”

INSTRUMENT PORTFOLIO

The 27+^® Portfolio includes Grieshaber^® ILM forceps, end-grasping forceps, MAXGRIP^® forceps and straight scissors. “I find it fascinating that Grieshaber can make 27-gauge forceps and scissors that function exceptionally well,” Dr. Charles says. “I have delaminated a diabetic traction retinal detachment case with the scissors and peeled ILM nicely with the ILM forceps. It is amazing to have moving parts in that size scale that will perform perfectly well, as good or better than the 25-gauge technology.”

Dr. Tabandeh also notes the 27+ endoilluminator provides excellent illumination at a setting of 40%, and Dr. Charles adds, “As the gauge becomes smaller, surgeons often become concerned about not having enough light, but light isn’t limited by the size of the fiber. You can provide a tremendous amount of light down a 27-gauge endoilluminator if the optical design is optimal. There is zero issue about the light being bright enough.”

The 27+ Portfolio also includes extrusion, laser and diathermy accessories.

OVERALL WIN FOR MIVS

Dr. Charles, who continues to develop new surgical techniques, has been an early adopter of small-gauge instrumentation with each downsizing, and he has never looked back. “I’ve done 33,000 vitrectomies,” he says. “Since 2003, I’ve performed only 25-gauge surgery for all of my cases. I’ve adapted everything I do, including forceps membrane peeling, scissors delamination and oil injection and reoperation under oil, to the 25-gauge method. I had an opportunity recently to perform 9 complex cases using the 27+ technology. Based on that experience, I envision being able to use 27+ for all of my cases.”

Dr. Tabandeh also routinely uses 25+ instrumentation and expects to transition to 27+, as well. “The 27+ portfolio is impressive in terms of performance and rigidity,” he says.

Dr. Charles is a paid consultant of Alcon. Dr. Tabandeh 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.

GAU13048PI

CONSTELLATION^® System with PUREPOINT^® Laser Brief Statement

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.

The PUREPOINT^® Laser is indicated for use in photocoagulation of both anterior and posterior segments of the eye including:

• Retinal photocoagulation, panretinal photocoagulation and intravitreal endophotocoagulation of vascular and structural abnormalities of the retina and choroid including: Proliferative and nonproliferative retinopathy (including diabetic); choroidal neovascularization secondary to age-related macular degeneration; retinal tears and detachments; macular edema, retinopathy of prematurity; choroidal neovascularization; leaking microaneurysms.

• Iridotomy/Iridectomy for treatment of chronic/primary open angle glaucoma, acute angle closure glaucoma and refractory glaucoma.

• Trabeculoplasty for treatment of chronic/primary open angle glaucoma and refractory glaucoma.

• And other laser treatments including: internal sclerostomy; lattice degeneration; central and branch retinal vein occlusion; suturelysis; vascular and pigment skin lesions.

GRIESHABER^® DSP Important Product Information

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

Indications for Use: GRIESHABER^® DSP instruments are a line of single-use vitreoretinal micro-instruments which are used in ophthalmic surgery, for cases either in the anterior or the posterior segment. The GRIESHABER^® Advanced Backflush Handles DSP are a family of instruments for fluid and gas handling in vitreoretinal surgery.

Warnings and Precautions:

• Potential risk from reuse or reprocessing GRIESHABER^® DSP instruments include: foreign particle introduction to the eye; reduced cutting or grasping performance; path leaks or obstruction resulting in reduced fluidics performance.

• Verify correct tip attachment, function and tip actuation before placing it into the eye for surgery.

• For light fiber instruments: Minimize light intensity and duration of exposure to the retina to reduce risk of retinal photic injury. The light fiber instruments are designed for use with an ALCON^® illumination source.

• Good clinical practice dictates the testing for adequate irrigation and aspiration flow prior to entering the eye. If stream of fluid is weak or absent, good fluidics response will be jeopardized.

• Use appropriate pressure supply to ensure a stable IOP.

• If unwanted tissue gets engaged to the aspiration port, it should be released by interrupting aspiration before moving the instrument.

ATTENTION: Please refer to the product labeling for a complete listing of indications, warnings, and precautions.