The right instrument can make all the difference during surgery. But as recent advances in use of femtosecond lasers show, instruments’ uses can change over time, changing common practice over time. What instruments do your peers prefer? The 2014 YO Info
editorial board shares their favorite instruments and how they use them.
Vitreoretinal Curved Delaminating Scissors
Not for every case (thankfully), but this instrument can be invaluable for severe diabetic traction retinal detachment in which the membranes are taut and the vitreous cutter is unable to define a good tissue plane for safe dissection. The scissor tips are useful as a pick to help find small membrane edges and identify the points of adhesion. The manually controlled cut is more gradual and intentional than the instant action of the vitreous cutter, so I prefer it when the retina is very tight against the membrane. I would offer a word of caution with respect to blunt dissection, however, as the adhesion points between the retina and traction membranes are often strong enough that simply pulling on them can induce iatrogenic retinal breaks. Nonetheless, used appropriately, these scissors are an effective tool in opening tissue planes to facilitate safe repair of diabetic traction retinal detachments.
Brian Chan-Kai, MD, is a vitreoretinal specialist at EyeHealth Northwest in Portland, Ore. Dr. Chan-Kai completed his residency at the Cullen Eye Institute/Baylor College of Medicine, where he also served as chief resident. He then trained in vitreoretinal surgery and diseases at the Casey Eye Institute/Oregon Health and Science University.
My favorite instrument is my needle-tip cautery. Painting across my tissue plane, I can simultaneously continue my dissection and keep a blood-free field. It comes in handy any time I need to separate soft tissue planes. What a great time and gauze saver. It also helps keep my scissors sharp!
Double-Armed Connor Wand/Koch Spatula
During cataract surgery, I like using a double-armed Connor wand and Koch spatula. My program director in Buffalo, Hoon Jung, MD, designed this instrument, and I have definitely found it useful. I can flip it around for use as a second hand instrument with my phaco or I/A handpieces without having to hand instruments back and forth.
James G. Chelnis, MD, is preparing for his oculoplastics fellowship, starting in July at Vanderbilt University. He is currently a senior resident at the University at Buffalo, where he graduated from medical school and was the school government president. In this role, he helped renegotiate the university’s health insurance terms with their provider, create a nationwide student–alumnus network, and organize a “Career Day” to place students in direct contact with physicians of all specialties prior to clinical rotations.
Bimanual Irrigation/Aspiration Handpieces
Some of my favorite instruments that I use routinely in cataract surgery are the bimanual irrigation and aspiration handpieces. Because of their delicate tips and your ability to switch hands, you can easily reach under the main wound as well as into the periphery of the capsular bag underneath the iris edge to get to dicey cortical material. They are very gentle for polishing the posterior capsule as well.
Rentsch Boat Hook
When suturing a 3-piece intraocular lens to the iris, I love to use the rentsch boat hook for easy retrieval of the 10-0 prolene through the paracentesis. After watching me struggle with a sinskey hook for this task, my perceptive scrub nurse suggested I try the boat hook and it worked like a charm. Love it!
Natasha L. Herz, MD, is a cataract, cornea and refractive surgeon who works as a solo practitioner at Kensington Eye Center in the Washington, D.C., metropolitan area. She completed her residency and fellowship at the Cullen Eye Institute at Baylor College of Medicine in Houston. Local peers selected her to appear in Washingtonian magazine’s Top Doctors of 2012 and 2013. She serves on the Academy’s Young Ophthalmologist Committee and has been the chair of YO Info editorial board since August 2011.
One of the keys to elegant and efficient surgery is simplicity. Less is more. Every movement in the eye should be purposeful, every instrument essential to the job. The ability for a single instrument to perform multiple tasks leads to even greater efficiency since there are less surgeon/tech hand off transitions. As a high volume refractive cataract surgeon, my favorite instrument is the Rosen chopper. It is capable of handling the softest to hardest cataracts with slight variations to my basic vertical chop technique. I also use the chopper turned sideways during final nucleus removal to keep the posterior capsule from surging forward. I keep the instrument palmed during I/A and then use it as a second hand gently depressing the IOL surface to keep my toric implants from rotating during I/A. Fast is slow, slow is smooth.
Edward Hu, MD, PhD, is a cataract specialist practicing at The Illinois Eye Center in Peoria, Ill. After graduating from the Massachusetts Institute of Technology, he received both his MD and a PhD in retinal electrophysiology from the New York University School of Medicine. He completed his residency at the University of Iowa Hospitals and Clinics, perennially ranked one of the top three training programs in the country.
Asymmetric Forceps and the Chandelier
I have a favorite vitreo-retinal forcep and a favorite lighting system. For macular membrane peels, I use the asymmetric forceps. The asymmetry and subtle angling of the tips allow me to see the fine tissue I am grabbing when the forceps are open. It eliminates the shadow that is often caused by the standard ILM forceps and allows for more direct depth perception rather than a game of “feel.” When a membrane edge is created with the asymmetric forceps, 100 percent of the tip’s surface is engaged with the retina for a secure grasp, compared to using only 50 percent of the standard ILM forceps surface area to pinch retina. Asymmetric forceps create good visibility for tissue depth perception and more of the forcep surface engages with the retina for a strong hold for peeling.
I also encourage all vitreo-retinal surgeons to use the small-gauge chandelier lighting system to free up your hands for true bi-manual surgery in select cases. It becomes critical when delaminating membranes in tractional diabetic detachments or when fishing for subretinal bands in proliferative vitreoretinopathy detachments.
Janice C. Law, MD, is an assistant professor at the Vanderbilt Eye Institute in Nashville. She received her ophthalmology training at the Kresge Eye Institute in Detroit, where she also served as chief resident. After a two-year medical and surgical retina fellowship at the Vanderbilt Eye Institute, Dr. Law joined the retina faculty as assistant professor in vitreoretinal diseases and surgery. Dr. Law is also the associate program director for residency education in ophthalmology and plays a very active role in developing curricula and assessing teaching and learning within ophthalmic education. She serves on the executive board for Tennessee Academy of Ophthalmology and is the vice president for Nashville Academy of Ophthalmology.
My favorite (i.e. most comfortable) second instrument for cataract surgery is the Seibel chopper. I learned horizontal chopping technique with this instrument and like its slim profile. I find it versatile in that you can obviously use it to chop but it fits easily into grooves for cracking with a divide and conquer approach. Also, it can easily be manipulated to help lift or flip pieces out of the bag. Plus, given the blunted end, it is difficult to cause a capsule tear with this instrument.
David E. Vollman, MD, MBA, is an assistant professor and assistant residency program director in the department of ophthalmology and visual sciences at the Washington University School of Medicine as well as a staff ophthalmologist at the St. Louis VA Medical Center. After completing an MD/MBA dual-degree program at the Ohio State University College of Medicine, he completed his ophthalmology residency at the Washington University/Barnes-Jewish Hospital/St. Louis Children’s Hospital Consortium Program where he subsequently served as chief resident. He has an active interest in ophthalmic health outcomes research and cost-effective care delivery.
Femtosecond laser-assisted cataract surgery has been a wonderful addition to my surgical arsenal. Femto-guided corneal relaxing incisions have improved the accuracy and reproducibility of the net desired effect with astigmatism correction. I use a 9-mm optical zone and an 80 percent depth, and although relaxing incisions will never be as accurate as toric IOLs for astigmatism correction, my outcomes are more consistently aligned with the desired effect. In addition to these refractive benefits, lens disassembly has become more sophisticated with the various patterns. Removal of the lens nucleus has become a quicker, safer and more efficient process, particularly in the setting of more mature cataracts. Femtosecond technology will continue to evolve and further refine modern cataract surgery outcomes.
Elizabeth Yeu, MD, is an assistant professor at the Eastern Virginia Medical School and in private practice in Norfolk, Virginia with Virginia Eye Consultants. Upon completion of fellowship training in cornea, anterior segment and refractive surgery at the Cullen Eye Institute, Baylor College of Medicine, Dr. Yeu stayed on faculty for several years before moving to Virginia.
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