Bausch + Lomb now offers 25- and 27-gauge Bi-Blade dual-port vitrectomy cutters for its Stellaris Elite vision enhancement system, giving surgeons more options when performing surgical techniques.

While single-port cutters only cut in the forward direction, Bi-Blade cutters cut in both forward and backward directions, enabling 2 cuts per cycle, explains Chuck Hess, vice president and general manager, U.S. Surgical, Bausch + Lomb. The innovative design offers an effective rate of 15,000 cuts per minute, resulting in increased flow efficiency and control compared to prior generation guillotine cutters. “Because the port of the cutter remains open for a longer duration, flow is increased up to 1.8 times the amount present in a single-cut vitrectomy cutter,” he says.

Sunir J. Garg, MD, FACS, professor of ophthalmology and codirector of the retina research unit at The Retina Service of Wills Eye Hospital in Philadelphia, Pennsylvania, wanted to try the cutters because he felt that the rate of vitreous removal and relative instrument flexibility of other systems could be improved upon. “Smaller gauge devices with high rates of flow enable me to perform many techniques, both simple and complicated, more efficiently than with a larger gauge cutter,” he says. “In addition, higher gauge systems create smaller incisions, which may decrease risk of complications such as postoperative hypotony and infection.”

Brandon Busbee, MD, physician partner at Tennessee Retina in Nashville, Tennessee, was prompted to try the cutters because he is always seeking out better ways to perform retinal surgeries. “With these new cutters, I can remove vitreous more efficiently and at the same time have a more stable internal environment for vitrectomy,” he says. “There appeared to be much less traction on the vitreous while cutting, which is a definite advantage with the Bi-Blade cutters.”

Using smaller gauge probes, such as the 27-gauge, reduces the need for additional instruments, such as scissors, says Hess. It increases efficiency by enabling the use of one instrument vs multiple instruments for various steps of a surgical procedure. It also offers the surgeon a level of precision and control through its ability to cut at a variety of different speeds and flow rates.

Another advantage, Dr. Garg says, is the instrument’s stiffness. “Traditionally, I was reluctant to routinely use 27-gauge vitrectomy as a standalone platform simply because the instruments flexed a lot, making it hard to do peripheral retinal dissection,” he says. “The Bi-Blade 27-gauge cutters are pretty stiff, making even complicated maneuvers along the vitreous base straightforward. Another advantage is that I can remove vitreous efficiently, even in cases of rhegmatogenous retinal detachment with mobile retina.”

CLINICAL APPLICATIONS

Surgeons can use the Bi-Blade cutters any time they want to remove vitreous and relevant tissues from the eye, Hess says. They can be used in core vitrectomies as well as macular holes and macular pucker procedures, as well as vitreous shaving and membrane removals.

In some diabetic patients with extensive traction retinal detachment, Dr. Garg will occasionally open a 23- or 25-gauge platform to gain access to instruments such as a lighted pick and various scissors, but he’ll also open up a 27-gauge cutter as a standalone instrument to use like a scissor. “This blended approach has enabled me to tackle even the most complicated cases more easily and safely,” he says.

Busbee, primarily a 25-gauge user and an occasional 27-gauge user, believes a small-gauge vitrectomy is a better environment to perform surgery, because there is less flow through the eye from the infusion.

For example, he has used the Bi-Blade 25-gauge cutter for bullous retinal detachments. At a cut rate of 7,500 cpm and at a low vacuum setting, he was able to remove vitreous appositional to the retinal interface with little or no movement of the mobile retina. The dual port and the efficiency of flow reduce the traditional traction and mobility when working close to a detached retina. “It is a game changer in doing more difficult surgeries when working close to the mobile retina,” he says.

Dr. Busbee prefers 25- and 27-gauge instrumentation for complex tractional detachments. The new Bi-Blade cutter allows for a more controlled environment while working with scar tissue. “Smaller gauges are more efficient for complex work,” he says. “The small-gauge Bi-Blade cutters are ideal for tractional retinal detachments.”

IMPROVING PATIENT OUTCOMES

When an instrument provides more stability in the vitreous cavity when performing surgery, outcomes improve. “Because there is less movement with this cutter, I feel that it is a safer instrument to perform surgery,” Dr. Busbee says.

“Any vitrectomy probe that allows me to spend less time in the eye, while providing better access to all parts of the eye and causing minimal retinal traction, is a huge advantage,” Dr. Garg says.

FINAL THOUGHTS

“I’ve always wanted a more efficient cutter. This cutter is truly in a class by itself compared to upgrades in other 25- and 27-gauge cutters I’ve seen in the past 10 years,” Dr. Busbee says.

The increased speed, efficiency, and rigidity of the instruments have largely removed any barriers to use of small-gauge vitrectomy, which is true for 25-gauge and increasingly true for 27-gauge cutters, Dr. Garg concludes. RP