April 2009 Insert Return to Homepage

Making the Most of Micro- Incision Vitrectomy Surgery

Disposable instruments increase the efficiency and safety of MIVS and are cost effective.

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Micro-incision Vitrectomy Surgery (MIVS) is truly a revolution in vitreoretinal surgery. Smaller incisions enhance patient comfort and introduce less trauma to the eye, lending to faster postoperative recovery times. Efficiency has always been an issue in retina procedures. Posterior segment surgeries tend to proceed more slowly than anterior segment procedures, and OR turnover times can be lengthy. More retina procedures are being performed in the ambulatory surgery center (ASC) setting, where streamlining has long been second nature and considered paramount to providing a satisfying experience for the patient. MIVS fits well into the ASC philosophy: the procedures are efficient, OR turnover times are improved, and the patient experience is excellent. Instrument options for MIVS come in both reusable and disposable technology and one must consider the benefits and liabilities of both when choosing one or the other. At Associates in Ophthalmology (AIO) in Pittsburgh, we have chosen to use disposable instrumentation, specifically, the GRIESHABER DSP (disposable instrumentation) line from Alcon Laboratories, Inc. (Fort Worth, TX; Figure 1).

EFFICIENCY WITH DISPOSABLE INSTRUMENTATION
Using single-use instrumentation has improved our practice’s efficiency by providing improved OR turnover because we do not have to sterilize the instruments between cases—we pre-stage the cases with the anticipated supplies/instruments that will be needed for the pathology at hand and then only open the appropriate instruments and accessories, as we need them. GRIESHABER DSP instruments help AIO combine efficiency with consistent instrument performance and increased quality of care.

CHOICES IN DSP INSTRUMENTATION
The ALCON DSP family of products provides a wide range of available tools and accessories, which allows you to choose an instrument that fits the case pathology. Multiple tip styles (Figure 2) including forceps and scissors, as well as accessories such as piks and backflush are available for use in 20-, 23-, and 25-gauge surgeries. The quality of the single- use DSP instrumentation is superb, the construction is strong, and the convenience factor is high.

PEARLS FOR TRANSITIONING TO MIVS AND CASE SELECTION
When transitioning from 20-gauge surgery to MIVS, the most important consideration is case selection. I recommend starting with macular cases, as we did. In my experience, the GRIESHABER REVOLUTION DSP forceps and scissors in 23 and 25 gauge have had a significant impact on my MIVS transition.The ILM forceps were critical in making me comfortable with MIVS.The DSP forceps provide stability, rigidity, and maneuverability for removing fine membranes. We choose to use them for all 23- and 25-gauge cases.

We then began to expand our caseload to include cases outside of the macula.The DSP soft-tip backflush has been useful because we can perform subretinal draining procedures (Figure 3).

For MIVS cases,we use a Superview BIOM lens (Insight Instruments, Stuart, FL); for the macular portion of the case,we use a disposable ocular vitrectomy magnifying (ODVM) lens to visualize the macula.We often use adjuvant staining with either preservative-free triamcinolone (TRIESENCE,Alcon Laboratories, Inc.) or diluted indocyanine green (ICG).

TRANSITIONING MORE DIFFICULT CASES TO MIVS
As a surgeon gains experience,more complex cases such as rhegmatogenous retinal detachments (RRD), tractional retinal detachments (TRD), and even some proliferative vitreoretinopathy (PVR) can be transitioned to 23- or 25-gauge surgery. The DSP scissors and serrated forceps have been especially helpful in our transition. The curved scissors are sharp and can be used for multipurpose cutting needs. Due to their grasping force, the serrated forceps work well for heavier,more adherent, tougher membranes. Using the Grieshaber Revolution DSP MIVS line, we have been able to peel tractional membranes, diabetic membranes, and PVR membranes with as much ease as we did with 20-gauge reusable instruments. For these more complex cases, a wide-angle lens is critical because it increases the comfort level for the surgeon as he adapts to the different feel of the MIVS case.

I would not, however, recommend MIVS for silicone oil removal, or any anterior-segment complication where a fragmatome is required because this technology is not yet available in small gauge. For these cases, such as retained nuclear fragments, or subluxed lenses, I still prefer to use 20-gauge technology. In the case of silicone oil removal, there are smallgauge cannulas available, but the process is slower. Ultimately, our ability to move more cases to MIVS will continue to improve our facility’s efficiency.

SUMMARY
In summary, the GRIESHABER DSP instruments are reliable, precise, convenient to use, and compliant with sterilization and cross-contamination issues. I use 23-gauge, and in some instances, 25-gauge technology for a wide variety of retinal cases, including epiretinal membranes (Figure 4),macular holes, straight vitreous hemorrhages, TRDs, RRDs (with or without scleral buckle), proliferative diabetic retinopathy cases, and simple PVRs (grade C2 or less)—and have benefited from the use of this DSP instrumentation.Additionally,DSPs add value to the AIO practice by combining efficiency with consistent instrument performance and increased quality of care for our patients.

Miguel A. Busquets MD, FACS, is a Partner with the Vitreoretinal Service, Associates in Ophthalmology. Dr.Busquets states he has no financial interests to disclose.He may be reached via e-mail at mbusquets@aioeyesurgeons.com.

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