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The infusion cannula is indicated for posterior segment infusion of liquid or gas. The gold standard in vitreoretinal surgery platforms. Discover more videos Upcoming events. Learn More. 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. 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. Abulon Djk. Clin Ophthalmol. Houston Sks Iii. In fact, it would often flex in a contrary direction, so if the surgeon wanted to go to the right, the instrument would flex to the left.
That was unexpected, because surgeons had never seen instruments behave like that before. In my practice, concerns with limitations in instrument performance excluded adoption of gauge surgery in virtually all patients. Alternatively, because gauge instruments handle similarly to gauge instruments, many surgeons initially preferred gauge surgery.
Issues with gauge surgery focused not on instruments but on wound construction something within the surgeon's ability to control enabling early adoption and easier transition. Today, there is a disposable instrument available in and gauge that is identical in function to virtually every gauge instrument that has previously been available, greatly facilitating the surgeon's transition to microincision surgery. The surgical event that requires transition is the introduction and stabilization of the transconjunctival trocars.
The learning curve is in establishing a comfort level of placing the gauge trocars into the eye in a stable and safe manner so that wound construction is associated with wound closure and trocar removal. With gauge systems, surgeons entered the eye with a straight, direct incision. This worked well, but as surgeons converted to and gauge systems, they found that many of these wounds would not close spontaneously.
Recent data have shown that an oblique entry, allowing secure trocar placement, establishes a stable closed sclerotomy with trocar removal and is best for both and gauge procedures. Alcon Laboratories, Inc. Significant advances in the next generation of trocar blade design has improved wound construction and closure Figure 1. Transitioning to gauge surgery has become easier with the introduction of next generation microincisional instrumentation. Trocar entry is best approached through an oblique entry for gauge cannula placement, though this step is not as critical as for gauge MIVS procedures.
Limitations to transitioning to gauge MIVS surgery were clearly associated with instrument concerns as opposed to transconjunctival wound construction. These next generation instruments significantly reduces inappropriate flexibility utilizing targeted manufacturing techniques, improved instrument design and enhanced materials when compared with the previous gauge instruments.
Along with instrument improvements, the new and gauge vitrector design has improved immensely, too. The port on the gauge Alcon vitrectomy probe has been moved closer to the distal tip similar to the gauge version; Figure 3 , and coupled with a dual pneumatic actuator and improved flow control, both the and gauge vitrectors will achieve 5, cpm with outstanding flow characteristics.
Historically, we have not used disposable instruments in gauge surgery. However, microinstruments have presented new challenges. In addition to the issues of sterilizing and storing the instruments, and gauge instruments are more likely to be damaged than gauge instruments due to increased fragility. Additionally, for high-volume practices, there is a significant cost to maintain reusable microinstruments. At Bascom Palmer, we maintain a fully staffed clean room, sterilize our instruments, and stock multiple backup instruments in case a particular instrument is not functional at the time of use.
Ultimately, we engender additional expense related to damaged instruments requiring out-sourcing for repair Figure 4. Disposables have been rapidly integrated into most clinical practices for and gauge surgery. As difficult as it is to maintain reusable gauge instruments, it is even more difficult to maintain and gauge instruments because they are smaller, less stable, and more easily damaged during normal processing and handling. Cost is also an issue. This concern, addressed in a review in Retina Times has not been supported with clinical concerns over the last decade.
Nonetheless, with disposable instrumentation, sterilization compliance is never an issue. Finally, there have been some concerns and an evolution in terms of sterilization requirements from the Joint Commission on Allied Hospitals. The concept of flash sterilization is no longer acceptable; full sterilization cycles are necessary. This means that surgeons may need multiple instruments sets that can be sterilized in a standard, non-flash manner.
With disposables, although a new instrument must be purchased for each procedure, they are sterile-packaged, readily available, and both effective and functional.
However, it actually gives chord length and hence can be erroneous at long measurement. Amsler caliper is the preferred one which actually measures the circumference.
Figure 5: A. MVR blade D. Trans sclera Cryoprobe: Cryotherapy results in aseptic inflammation from thermal injury, later resulting in the formation of chorioretinal scars. Cryotherapy is based on the Joule-Thompson effect: a change in temperature of the gas on sudden changes in volume and pressure. At room temperature, gases cool on expansion. Gases with a high positive Joule-Thompson coefficient have a greater temperature drop for a given pressure change.
Nitrous oxide among all having the highest Joule Thompson coefficient and hence having the highest temperature drop makes it gas of choice for cryotherapy. In pre-MIVS era, it was the first instrument used to create a pars plana entry and hence was an essential instrument in any vitrectomy surgery. After the introduction of the trochar-cannula set in MIVS, the role of this instrument is mainly limited.
Infusion cannula: initially in 20G vitrectomy system, the infusion cannula was a slender metallic holo tube with a grooved collar.
The grooved collar was used to put the suture to fix the cannula with the sclera. Originally, infusion cannula was available in 3 different lengths of 2mm, 4 mm, and 6 mm. Most commonly used infusion cannula were of 4 mm length, however, 6 mm long cannula were also designed to tackle special situations like vitrectomy in presence of thickened choroid or choroidal detachment.
In MIVS, The infusion cannula fits through the microcannula array and hence there was the elimination of the collar from the design and there was the introduction of sliding lock design on the outer surface to ensure snug tight-fitting.
Figure 6 : Infusion canula A. Depth of the slot will act as an incorporated caliper to measure the distance between the limbus and trocar entry site, while serrations on the under surfaces allow a good hold on the conjunctiva for misalignment over the proposed scleral entry. Dugel modification allows the pressure plate forceps to make a biplanar incision. The Thornton or Shepard fixation ring has also been utilized for globe stabilization during trocar insertion.
The most important development of small-gauge vitrectomy was the introduction of a trocar-cannula system. Trochar-cannula rests inside the sclera and provides an easy introduction of instruments, it protects the sclera against direct injury through the instruments, and entry site with a trochar-cannula system is much easier to find than a usual sclerotomy. The disadvantage of the trochar-cannula system compared to the usual sclerotomy is the excessive leakage of fluid through the cannula during the exchange of instruments.
To cop up with that, later on, the valved trochar-cannula system came into light. The valve maintains the globe as a close chamber and hence stable fluidics is achieved continuously with the low fluid infusion.
Valves prevent the incarceration of vitreous into the trochar-cannula and hence in sclerotomy. Valves build up a higher intraocular pressure, which is useful during a fluid—air exchange or removal of a preretinal oil bubble; and reduce the need for plugs.
The presence of the valve in the cannula makes the entry of the silicone soft tipped instrument difficult. Valved cannula should be avoided during the removal of silicone oil. It is important to check the tip of the trochar cannula under the microscope before using it for sharpness and to rule out the bent tips in view to achieve self-sealed sclerotomy.
Braunstein fixed caliper marker: Its a caliper made specifically for vitreous surgery having peaked both ends with 3. Plugs: The cannula plug is used to seal the cannula after insertion into the eye wall. It is designed with a tapered shaft or a tight sliding fit to seal within the cannula port. The plug should be inserted only as far as necessary to seal the cannula.
Forcing the plug too far within the cannula may cause problems during removal. Even with proper plug insertion, counter-force should be applied to the cannula hub when removing a plug. With the invention of the valved cannula, there is a significant reduction in the use of the plug during surgery. Plug removal forceps: Specialised forceps having cross action with the groove at the tip to hold the plugin the proper position for insertion as well as removal.
Vitrectomy cutter: it is the single most important essential during even the smallest vitreous procedure like Vitreous biopsy and hence it is the instrument that had undergone several modifications from its introduction as a VISC in the s to till the date. The main objective and goal were to convert high-performance skills demanding surgery into safe and more successful vision rewarding surgery.
Being an electrical motorized, they were too costly to be disposable. The electric motor was also contributing rotary movement known to cause some amount of traction and the weight and size of the motor were making the instrument somewhat bulkier. Figure 9: Image about Vitrectomy cutter: A. Mechanism of Pneumatic spring cutter B. Mechanism of Doble Pneumatic cutter C. Tip port relationship of cutter E. The pneumatic spring return is driven vitrectomy cutter: An air pulse pushes down the diaphragm located inside the vitrectomy probe, leading the port to a closed position the guillotine movement ; at the same time, a spring is compressed and forces the diaphragm back to the open port position.
The biggest advancement was that pneumatic cutter were significantly lighter in weight and having a significant reduction in rotary gullitone movement to avoid traction. Limitation of this was, as cut-rate increases the duty cycle decreases to some degree over all the gauges, and hence individualization of cut-rate and duty cycle was not possible.
InnoVit was the 1st version of this. Double pneumatic cutter: Instead of using a spring to return the guillotine to the original position, the dual pneumatic probes use separate airlines to both open and close the vitrectomy port. Advantage of this modification is, this allows the duty cycle to be controlled independently of the cut-rate with customized modes, for e. Aperture in the piston allows continuous and even flow due to the two open cutting ports. Two sharp edges over piston allow cutting vitreous in a forward and backward movement during each cycle, effectively doubling the cutting speed.
This novel technology reduces vitreous traction, decreases surgical time, and increases the safety of surgery. TDC cutter has 1. Constant use of adequate illumination via light source throughout the surgery also induces localized thermal changes and hence Spectrum of light used in light source, efficacy, safety, life of light source were few among the many important driving force for constant advancement in this instrument. A halogen lamp: It has a long lifetime without darkening due to the halogen cycle.
The spectral irradiance of halogen lamps has a peak of nm. Metal halide lamps: These are high-intensity discharge lamps.
The compact arc tube contains a high-pressure mixture of argon, mercury, and a variety of metal halides. The argon gas in the lamp is easily ionized and facilitates striking the arc across the two electrodes when voltage is applied to the lamp. The heat generated by the arc then vaporizes the mercury and metal halides, which produce light as the temperature and pressure increase.
The mixture of halides affects the nature of light produced, influencing the color, temperature, and intensity making the light more blue or red. The spectral output has two peaks at nm and nm. Xenon lamps: They are high-intensity discharge lamps.
Light-emitting diode lamps: This relatively new light source offers several advantages. It is so much compact that, it can be directly fixed in the probe and obviating the need for a separate lightbox and fiberoptic cable. It has two spectral peaks: nm and nm. The proportion of harmful blue light is low as compared to xenon light source, with or without nm filter. It is not only the source of light that had undergone advancement but also the type of fiber optic used and light probe too are important aspects.
There are various types of light sources available nowadays. Straight: projects a narrowly focused beam, yielding an enhanced Tyndall effect. It is useful for vitreous identification. Bullet type: projects a wide field of highly scattered light that is ideal for diffuse surface illumination and panoramic fundus view.
Shielded light pipe: A small hood is designed to be placed over the bullet tip, so that glare toward the surgeon can be reduced. Wedge type: provides a hybrid illumination with both focal and wide-field illumination characteristics due to an asymmetric light cone.
Backscatter or surgeon glare is maximum with the bullet probe, followed by straight and significantly lower with wedge-type aperture. Chandeliar illumination system: A chandelier light provides a panoramic light source and illuminates the entire fundus. It is fixed as a fourth port. A chandelier light is either fixated directly in the sclera or in a trochar-cannula. In general, scleral-based fixation is used for eyes that are not vitrectomized and the trochar-cannula - based chandelier light for eyes that are vitrectomized and have a soft globe.
This enables bimanual surgery and allows the surgeon to use a second active instrument in addition to the vitreous cutter. In 27G an Eckhardt twin light chandelier is available. For optimal illumination of a chandelier light, an external light source Photon, Xenon or a modern vitrectomy machine Stellaris PC, Constellation, Eva is required.
Figure Light source used during vitrectomy. Comercial available light source B. Graphic suggestive of different design of light source and their role C.
Endolaser probe: The first endophotocoagulation probe was developed by Charles in and he only first reported endophotocoagulation using a fiberoptic probe attached to a portable xenon arc photocoagulator. The most frequently used endolasers for vitreoretinal surgery today are the green and infrared diode laser. Laser tissue interaction principles even in surgical lasers are the same as photocoagulation and the effect depends upon the distance of the probe tip from the retina and angulation of the tip relative to the retina in addition to the standard parameter like laser power, duration, and pigmentation of retina.
The xenon arc beam was divergent and hence the tip had to be positioned close to the retinal surface. The argon laser had a smaller angle of divergence enabling the probe tip to be positioned at a safer distance from the retina. Argon laser is also capable of rapid repetitive laser applications and could be used through air or fluid in contrary to xenon arc laser. The fiberoptic had an outer diameter of 0. The diode laser is commonly used nowadays in vitreoretinal surgery.
It is cheap, compact, portable and comes in infrared and green wavelengths. The clinical appearance of the burn while it is being made is similar to that with argon laser, but it is subtly lighter, especially in less pigmented eyes.
Endolaser probes may be straight or curved and the recent one is having an adjustable, retractable tip. The straight probe provides direct access to the treatment site and facilitates easy access through the sclerotomy site. Angled probes curved tip are useful for applying endolaser anterior peripheral retina in addition to reduces the risk of lens touch in phakic eyes.
Probes with adjustable tips have a fiberoptic which can be continuously adjusted over a wide range of angles for full coverage of peripheral retina and hence having the advantage of both straight and curved laser probe.
Other uses of this laser with the probe are cyclophotocoagulation and correopexy. Eckardt wound closure spatula: Proximal end of handpiece features a blunt insertor that facilitates re-insertion of 23 gauge cannulas. The tip has a V-shaped guided design with a knob-controlled pressure plate that promotes self-sealing of incision by applying exact pressure at the sclerotomy site. Basically it works on the principle of the pressure gradient. The pressure difference between the intraocular pressure and the lower atmospheric pressure, when side port is not covered is a force for passive egress of fluid.
In larger 19 — 20G surgery, this instrument can be of uniform diameter or tapered tip. The advantage of a tapered tip is limited fluid egress causes reduced outflow and hence more effective while working close to the detached mobile retina or at the posterior break.
In MIVS, this needle is also available with a soft silicone rubber tip to minimize direct tissue trauma. A special handpiece has also been designed with a soft silicone catheter within the needle that can be advanced and used as an active suction. It can be unipolar and bipolar, but bipolar is preferable to minimize stray current that might be conducted by the optic nerve.
It can be co-axial or bimanual. Coaxial bipolar diathermy is preferred for marking retinal break and creating a drainage retinotomy, while bimanual bipolar diathermy is preferred to stop bleeding from elevated fibrovascular tissue. In case of bleeding from the inner retinal surface, diathermy of the choice is again coaxial one, which creates a small elliptical field of current around the tip, and hence bleeding site can be treated without tissue mass to hold in-between.
It should be avoided on or close to ONH. Electrocautery presently used with a recent constellation machine is a high frequency 1. Proportional control eliminates the need for an assistant to adjust the optimum power and intensity. Higher frequency produces a more focused lesion probably limiting the collateral damage. There are series of instruments with different tip designs including the varying degree of angulation, contour, and sharpness to permit dissection from a different direction and to engage tissues of different consistencies.
The most common variety of pic used is the one with tapered tip angulated 90 degrees. PFCL being a low viscosity liquid, can be injected through small microlumen easily hence dual lumen cannula came into to picture. In this cannula, the lowermost opening is for entry of PFCL into the vitreous cavity, all the middle opening are for BSS in the vitreous cavity to enter into canula to go out while uppermost opening opens into the exterior to drain out the BSS. They are really useful, especially with Valved trochar cannula.
Endocryo probe: Intraocular cryotherapy is applied with a straight cryoprobe with a 1. An iceball forms surrounding the tip and envelops the retina and underlying RPE and choroid. So here it can be useful in a case with albino fundus or wherever surgeon wants to create chorioretinal adhesion in presence of RPE atrophy.
It is important to defrost the probe before moving it to avoid tearing of retina and the underlying choroid. They have been developed to a temporary secure portion of the retina to choroid and sclera in GRT, the eye with extensive retinotomies.
It is 0. Nob Spatula: One of the ancient instruments available in only 20G, used for massaging the edge of the retina in an attempt to unroll or flatten the edge of GRT or relaxing retinotomy. Membrane peeling forceps: They are of several types with varying sizes, shapes, and compositions. Some have both peeling and grasping, some are diamond dusted to prevent membrane slippage from the forceps.
Advances visualization with customized illumination, enhanced optical clarity, and reliability 1. Built to improve peripheral access and built-in illumination for visibility 2. Delivers the performance you expect with an integrated photocoagulator. Designed to help you work more freely, securely, and precisely.
Engineered for ILM peeling so you can grasp and peel with precision. Optimizes consistency to help you to initiate your ILM peel with confidence. The Alcon Professional Events portal gives you access to surgical retina events happening around the US.
As the global leader in surgical retina, Alcon represents not only quality and continuous improvement, but also an indispensable partner providing breakthrough technologies that can help you improve your patient outcomes and your practice. Perform the way you want today. Learn more about the latest from Alcon. Evaluating ref reflex and surgeon preference between nearly-coillimated and focused beam microscope illumination systems.
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