New vitreoretinal tools advancing surgical outcomes

For surgeons, the attention to detail in new technologies being offered today is allowing them to perform safer, more efficient procedures. 

This article was reviewed by David R. Chow, MD, FRCSC.

Advances in the technologies used by retina surgeons are moving ahead at a rapid-fire pace. Dozens of new devices that are smaller (and sometimes larger), shorter, brighter, and lighter have recently become commercially available with the hope of making surgeries easier and more efficient. David R. Chow, MD, FRCSC, detailed several new tools for physicians to consider adding to their practices.

Dr. Chow is assistant professor of ophthalmology, University of Toronto, St. Michaels Hospital, Toronto Retina Institute, North York, Canada.

Vitrectomy cutters
Bausch + Lomb has introduced a bi-blade dual-port vitrectomy cutter with an innovative dual-blade design that features a cut rate of 15,000 cuts/minute and is available in three gauges: 23, 25, and 27. The instrument can increase balanced saline flow by 230% and increase vitreous flow by 180%.

Bausch + Lomb also has developed the Vitesse Hypersonic Vitrectomy probe that boasts a new cutting concept, in that the needle is mounted to a piezoelectric ultrasound transducer that vibrates harmonically resulting in a cut rate greater than 1 million cpm. This instrument has been used in more than 200 procedures worldwide with a wide range of vitreoretinal pathologies. It can effectively remove vitreous, lens material, membranes, and silicone oil.

Alcon is offering the Hypervit Dual-Blade Vitrectomy Probe that is capable of 20,000 cuts/minute. This instrument has a beveled tip design, which lets it move up to 50% closer to the retinal surface; it is available in 25- and 27-gauge. A new prototype probe, the multiport vitrectomy cutter features an outer sleeve that can be rotated to expose three ports. 

“This exposure of the additional ports facilitates higher flow rates,” Dr. Chow said.

Cataract and vitrectomy systems
DORC announced pending upgrades to the Eva cataract and vitrectomy system. The footswitch has been redesigned and now has integrated laser control with improved ergonomics. The second improvement is in the 27-gauge light output, which improves output by 65%, and a new LED module adds another 30%, which allows optimal 27-gauge light output.

The company is also marketing a 27-gauge ultra-short vitrectomy kit that includes a trocar/cannula that is 25% shorter, a vitrectomy probe that is 25% shorter and 60% stiffer, and a light pipe that 20% shorter and 65% brighter.

Ngenuity with Datafusion has been integrated into the Constellation platform (Alcon). This innovation allows real-time display of the Constellation parameters on a monitor. 

Infusion system
Bausch + Lomb has developed the Freeflow infusion device, which is an infusion line that is placed over the infusion cannula to maximize the internal diameter of the cannula. This improves flow rates by up to 40% and will be useful with the bi-blade vitrectomy probe to maintain infusion at high flow rates.

Internal limiting membrane stain
DORC is currently trying to bring Brilliant Blue dye  to the U.S. market. The dye is currently being reviewed by the FDA.
“This is potentially the first FDA-approved staining agent for identification of the internal limiting membrane [ILM] intraoperatively,” Dr. Chow commented.

Subretinal retinal injection devices
Three new such devices are becoming available this year. Altaviz is releasing a microvolume injector with dose guidance; it is a self-powered stand-alone device, for use in stem cell and gene therapy. Besides providing visual and audible dose guidance, the injector also allows Bluetooth connectivity that displays the progress of the injection and the metrics.

Another injector from MedOne is the Nano Cannula, a 48-gauge metal, beveled-tip cannula that is specifically designed for use in subretinal procedures.

Vortex has designed the Nano Subretinal Gateway Device that is designed to be used in the absence of a vitrectomy. This injector includes a 28-gauge needle, designed for transscleral injections, with an extendable beveled tip, 41-gauge flexible cannula that facilitates injections into the subretinal space. 

Forceps device
Larger and smaller forceps handles have been introduced by Alcon, which have been designed for use by surgeons with large and small hands.

The Stiff Dex (Katalyst) is a 19-gauge telescoping stiffening sleeve on a 27-gauge forceps, which allows the forceps to have a much stiffer profile. 

The Reddy end-grasping forceps (Bausch + Lomb) features microserrations with a long grasping platform and a window for visualization.

The Sharkskin ILM forceps (Alcon) features laser-ablated microstructures that are 10 x 10 x 5-μm teeth that point toward the grasping edge, which increases the kinetic friction between the forceps and tissue. A second feature is a conforming platform that reduces by 50% the indentation force needed to grasp the ILM. Both features increase grasping ability. 

Chandelier system
Vitreq now has the 29-gauge Spotlight directional chandelier system that uses a unique fixation system to the drape above the patients brow to direct a wide-view light beam with a 29-gauge trocar cannula.

Cannulas
A membrane-peeling Cannula (Katalyst) has burrs on the lateral edges to cut the ILM and a spatula shape with active extrusion to engage and remove the ILM flap. After removing the membrane, the same cannula is used to perform an air/fluid exchange.

MedOne is reintroducing the 27-gauge VFI Cannula with a Luer lock, which is the only all-metal 27-gauge oil-injection device. It has very thin walls to maximize the internal diameter of the cannula for speedy oil injection.

A 38-gauge cannula designed by Carl Claes, MD, has a 38-gauge tapered tip that is available in 23- or 25- gauge that is used to drain or close macular holes under silicone oil with active extrusion.

Portable laser
The new FDA-approved Leaf Ultracompact Green Laser (Norlase) weighs three pounds and connects to a slit-lamp without any external cables. The laser is controlled wirelessly by a tablet.

New microscope
Alcon is now offering the Luxor Revalia Ophthalmic Microscope that incorporates an objective lens placed above the light source allowing enhanced depth of field, and three LED options for personalization of the illumination quality: warm cool, or mixed white.  

Scleral depressors
Vortex Surgical now has the EDD (external drainage and depression), a scleral depressor that includes a retractable 28- gauge needle 2.4 mm long and can be connected to active extrusion.

The third scleral depressor, Sclerex from Natalia Vila, is a mechanical scleral depression device that attaches to a lid speculum.

New needle design
Lyubomyr Lytvynchuk, MD, designed a needle to perform intravitreal injections. It has a solid tip that may require less force during injection, and a proximal injection port that may reduce the amount of cellular tissue that is dragged into the eye during injections.

David R. Chow, MD, FRCSC
E: davidrchow@me.com
This article was adapted from Dr. Chow's presentation at the American Academy of Ophthalmology 2019 annual meeting. Dr. Chow has no financial interest in any aspect of this report.