Retina Today - Portable Vitrectomy Today (January/February 2016)

摘要

As experience with small-incision sutureless vitrectomy has grown, 23- and 25-gauge instruments have been widely adopted by retina specialists.1 Oshima et al described 27-gauge vitrectomy with a 0.4-mm incision in 2010, and, since then, several companies have introduced 27-gauge platforms.2 Although three-port pars plana vitrectomy (PPV) has overwhelmingly been the preferred procedure for nearly 40 years, interest has recently turned to using portable surgical technology and fewer ports for selected clinical indications, such as vitreous biopsy and removal of vitreous opacities. One reason for this interest is the potential to move some procedures into the office setting. Manufacturers now produce vitrectomy systems that allow surgeons the flexibility to decide on the most appropriate location to perform a procedure.3 AT A GLANCE • The mainstay of vitrectomy has been three-port PPV, but there has been recent interest in the use of portable systems and fewer ports for certain cases. • Office-based surgery, by definition, must be tolerable under local anesthesia. • The combination of portable vitrectors and minimally invasive surgical techniques may make office-based vitrectomy more commonplace for carefully selected patients. The setting for surgical procedures is at the discretion of the surgeon based on clinical needs and preferences; there are no prohibitions on place of service based on the Medicare Physician Fee Schedule. If a vitrectomy is done in a hospital or ambulatory surgery center, Medicare pays a separate facility fee. For in-office vitrectomy, no facility fee is paid. The physician fee is the same (based on CPT code), regardless of additional overhead (eg, supplies) incurred by the practice. My definition of a portable vitrector is any vitrectomy unit that is easily transported between the OR and office, compatible with office-based vitrectomy, and able to run on battery power. This article takes a look at available portable vitrectomy machines and their potential clinical uses. PORTABLY SPEAKING Intrector The Intrector portable vitrectomy system (Insight Instruments) features a cutting speed of more than 1200 cpm. Its guillotine-style vitrector has a dual-lumen 23-gauge probe that contains a central infusion channel and peripheral aspiration/cutter channel connected to a 3-mL syringe for manual aspiration (Figure 1). Illumination can be provided either by an operating microscope or a binocular indirect ophthalmoscope with 20-D lens. Figure 1. Schematic of the Intrector dual-lumen probe (A). Intrector control box (B). The disposable Retrector vitrectomy probe (Insight Instruments) incorporates a retractable 23-gauge needle for insertion with a blunt-tipped vitrector aimed at making peripheral vitrectomy safer. An accompanying 26-gauge sharp-tipped infusion cannula is designed for optimal scleral retention. VersaVIT 2.0 The VersaVIT 2.0 (Synergetics) is a high-speed, 6000-cpm fully functional vitrectomy system that can run on either a CO2 canister or compressed air (Figure 2). Easy-to-use duty cycle control offers the surgeon flow control independent of vacuum, and a dual LED light source provides safe, clear, long-lasting illumination. Weighing 25 lbs, the VersaVIT 2.0 has a built-in handle for easy portability and can be battery- or AC-powered. The device boots up in 10 seconds and features an intuitive setup and quick prime cycle. It includes illuminated endolaser probes, soft-tipped extrusion cannulas, and silicone oil removal cannulas that are available in 20-, 23-, 25-, and 27- gauges and can be inserted through valved ports. The device costs about half as much as full-sized systems, and the disposable packs are about 80% less expensive. Figure 2. VersaVIT 2.0 system (A), wheeled carrying case (B), and battery power pack (C). A PLACE FOR OFFICE-BASED VITRECTOMY Portable vitrectors are not meant to replace current OR surgical technol