To weigh in on some of the latest developments in the vitreoretinal field and what innovations may be next, we've consulted the following industry leaders.
To review each individual's observations, click on the links to expand each of the sections below.
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Tim Murray, MD
Learn MoreWhen removing the cannula, you want to follow the dynamics of your wound as you exit. Grasp the conjunctiva around the cannula, stabilize the cannula and remove the cannula in the same tract that you entered. As you remove the cannula, make sure you slip the conjunctiva back and close the sclera with your forceps to stabilize the sclera.
I first remove my supranasal and supratemporal sclerotomies, then my infusion cannula over the light pipe so that I don't have an internal ostium. I want to minimize the potential for vitreous wick syndrome, potentially associated with iatrogenic tear or iatrogenic-related endophthalmitis. I evaluate and massage that area to be certain that it is closed.
I like to have the IOP in the eye stabilized, with my plugs in place. I remove the plug with the infusion off, place the light pipe through and then retract over the light pipe. Then I restabilize the IOP with the infusion and remove the second and third ports.
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Steve Charles, MD
Learn MoreThe first-generation 25-gauge trocar-cannulas had high insertion force, which created stabilization issues. The second-generation trocar-cannulas have low insertion force, roughly equivalent to that of a 20-gauge microvitreoretinal (MVR) blade, so stabilization of the eye is no longer a problem.
I use a cotton-tipped applicator to displace the conjunctiva and hold the eye in position. After displacing the conjunctiva and laying the blade on the eye, I drop the cotton tip and use the forefinger of my free hand to triangulate. This way, I support the ferrule of the trocar with a two-handed approach.
This keeps the eye very stable, preventing rotation or displacement, and it lets me continue with a near-tangential approach. Initially, like most surgeons using the straight-in system, I had a few wound leaks, although no endophthalmitis, and so I developed the notion of fluid-air exchange. Other surgeons have conducted short comparison trials that appear to show that fluid-air exchange made no difference in outcomes.
I was elated when the angulated scleral tunnel wound was developed. This wound architecture is necessary when using 23-gauge instrumentation. I have been using it for my procedures for slightly more than a year. Every wound is constructed with very tangential initial trajectory. I tilt up, using a technique that some surgeons call "supination."
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Allen Ho, MD
Learn MoreStabilizing the eye is the first step in creating a reliable, self-sealing wound. In my hands, it is very different for 25-gauge versus 23-gauge systems. If you create an appropriately angled wound, the forces for 23-gauge entry are significantly greater than the forces for 25-gauge entry. These forces not only rotate the eye circumferentially but also in a posterior direction, deep into the orbit. So my fixation techniques have evolved in a couple of ways.
For 25-gauge, all I need are forceps to grab at the limbus or cotton-tipped applicators to stabilize the globe to create an angled incision. Also, I try to pass the bevel of the trocar as flat as I would pass a scleral suture by a first scleral buckle. I strive for very flat penetration initially so that I can seal within the scleral tissue itself.
For 23-gauge, I almost exclusively use the Thornton Fixation Ring, a swiveled, semi-circular ring with a handle that cataract surgeons use to stabilize the eye during clear cornea procedures. The ring helps me fixate the globe when significant 23-gauge forces rotate it in an anterior-posterior direction. I then displace conjunctiva by grabbing the conjunctiva with the tip of the trocar, moving the conjunctiva and going flat into the eye with an angled incision through the sclera.
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Pravin U. Dugel, MD
Learn MoreDuring the last decade, technologies like small-gauge surgery and intravitreal drug delivery have transformed retinal surgery. Now we are witness to another significant development. Medicare has more than doubled the ASC facility fees for the most common retinal surgeries, making it economically feasible for many ASCs to host these procedures. This change not only creates financial opportunity; it means better care, since retinal surgeons will have much more input into staffing, instrumentation and supplies.
For the last decade, I've been doing 20 to 25 retinal cases per week in our ASC. Based on that experience, here are two pieces of advice for ASCs pondering whether to make the transition to retina:
1. Look before you leap.
Adding this subspecialty can be wonderfully rewarding, but it requires a significant commitment in money, time and effort. Consider the decision carefully. It's not for everyone. Assuming you already have a surgical microscope, plan to invest about $250,000 for the capital equipment and instruments.
Even if you are already in a single-specialty ophthalmic center, your staff will need intensive, continuous training in retinal surgery, surgical technology and perioperative care. When the surgeon needs a change on the laser, vacuum, or cutter, there's no time to dither; scrubs and circulators need to thoroughly understand the technology. At our center, we are also intent on perioperative efficiency, and we've devoted a lot of study and practice to it. Whereas local hospitals take from 45 to 70 minutes between retinal cases, our staff can now turn over our rooms in 11 minutes, and we're working toward seven.
2. Choose your surgeon(s) wisely
We have a lot of great retinal surgeons in the U.S. but not are all cut out to do cases in an ASC. The surgeon with whom you should partner:
Moving retinal cases into an ASC makes a palpable, concrete differences in outcomes; I've seen it with my own eyes, and it has turned me into a passionate advocate for ASC-based retinal surgery. Now that the federal government has seen the light, I consider it our opportunity and our duty to make the transition happen.
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