With heart disease and stroke as the number one and number three causes of death in Maryland according to the Maryland Department of Healthevents like the Greater Maryland Heart Walk are https://dsamglobalconcepts.com/highmark-medicare-essentials-planner/9040-adventist-health-study-vegans-lowest-risk-of-chronic-disease.php now more than ever. Assist and support public and private health care initiatives for individuals without health insurance. A virtual member ID card can be accessed via your My Account portal. By launching a recent witu sponsorship with the American Heart Association, CareFirst is is carefirst ending their relationship with magellan an ideal position to leverage a well-earned wave of momentum aimed at supporting the work of both organizations as they strive to enrich the lives of people across this region is carefirst ending their relationship with magellan the United States. Out-of-pocket costs may increase significantly. Relationshup a new agreement is not reached, the termination for the physician group will be effective on December 5,resulting from a day notice requirement. We have set up a dedicated call center open Monday through Friday from a.
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. Additionally, there is no concern of damaging the instrument during the procedure. No back-up instrumentation is required, and surgeons have access to have a wider spectrum of instruments.
In other words, you can have a broader range of disposables available at a much lower facility cost. Initial limitations in the armamentarium of disposable and gauge instruments have now been eliminated.
In my opinion, Alcon has essentially every major instrument including forceps, scissors, backflush and pics in a disposable format for both and gauge procedures Figure 5.
I have compiled a list of some of the reasons that I use disposable instrumentation in Table 1. These instruments potentially improve surgical management elimination of damaged instruments and patient safety elimination of reprocessing compliance issues. These instruments are unique in that they are new at the beginning of each procedure. Finally, there is no concern of performance issues related to compromise of the instrument over time while the quality of the disposable instruments has achieved an exemplary standard.
In the past, surgeons have been concerned that disposable instruments were not available in the range of instruments necessary to manage complex retinal pathology, did not meet quality standards comparable with non-disposables, and were prohibitively expensive to be utilized in routine surgery. These are clearly concerns of the past with the delivery of next generation disposable instruments that are reliable, precision-crafted, compliant and convenient and deliver to the surgeon and the patient the best instrumentation for microincisional vitrectomy surgery.
Timothy G. Murray reports that his is is a Consultant for Alcon Laboratories, Inc. He can be reached via e-mail at tmurray med.
Supported by Ocular Therapeutix , Inc. January Vitreoretinal Surgery Features Disposable Instrumentation for Microincision Vitrectomy Surgery Surgical results, precision performance, and sterilization concerns are discussed. The biggest advantage of using noncontact systems is the ability to operate without an assistant. They also allow excellent theoretical degrees of visualization and the capability to work in the far retinal periphery without prisms.
Furthermore, this technology allows quick exchange from anterior-segment surgery to posterior-segment visualization. The noncontact visualization platforms also allow quick exchange of lenses to perform high-magnification macula work. However, one drawback is that the lenses may fog easily and do not provide with the widest or most magnified views. Furthermore, noncontact wide-angle viewing of the periphery requires much greater ocular rotation and instrument flex, which is a concern when using smaller-gauge instruments.
The Resight system can magnify and focus with the microscope pedal. This allows quick visualization in the retinal periphery, in the macula, and when complex pathology is present. Victor M. Timothy G. Villegas reports no related disclosures. Murray reports research activity with Regeneron, personal fees from Alcon, and fees from the National Cancer Institute. Reach Dr. Villegas at v. Various contact lenses are currently available from different manufacturers.
Wide-angle contact lenses allow the widest angle of visualization and the sharpest image. Because they are touching the eye, a contact lens allows correction of corneal aberrations and therefore provides unparalleled visibility.
Furthermore, due to the shortest possible working distance, true degrees of visualization is possible. We currently use wide-angle contact lenses for primary repair of giant retinal tears and pediatric vitreoretinal surgery. Several companies have disposable contact lenses with stabilizing legs that allow for magnified 25 to 36 degrees of visualization. In certain situations, one or more of the stabilizing legs may be trimmed off for a perfectly customized fit.
Magnification ranges from 0. Aspheric contact high-resolution vitrectomy ACS Lenses Volk Optical deliver the highest resolution direct image of the central retina due to the use of high-index glass. These lenses are suited for repeated steam sterilization with no material degradation and can be used with or without suture rings.
High-resolution contact lenses can be useful for membrane peeling, transvitreal choroidal biopsies of the posterior pole, macular hole surgery, posterior hyaloid stripping in pediatric cases, and complete fluid-air exchange when complex pathology is present.
Microincision vitrectomy systems , , and gauge have evolved significantly over the last decade Figure 1. The advantages of these microincision systems include improved safety by reducing iatrogenic breaks due to peripheral traction during insertion and removal of instrumentation through the trans-scleral cannula system.
All of them offer phacoemulsification and vitreoretinal capabilities, and they are equipped with a nm laser. Figure 1. The Constellation , , and gauge provides the ability to control duty cycle and flow vacuum independently. It also boats a bright Xenon light source.
The widespread availability of this system is arguably the most important feature since the majority of US-trained surgeons have had experience with this platform. The EVA , , and gauge system has recently gained traction in the US retina community mainly due to the revolutionary fluid control system that uses valve timing intelligence.
This technology eliminates the risk of unwanted pulsation or unwanted flow seen in peristaltic pumps. The vacuum and flow modes coupled with a 2-dimensional cutter gives the surgeon a new level of control. The LED illumination in this system will last longer than other systems, and color tinting options allow the surgeon variable tissue contrast for enhanced visualization.
However, some surgeons may still prefer the xenon lighting system due to warmer color tones. However, this platform is not available with gauge trocar-cannula systems. The newest Stellaris Elite is available with gauge trocar-cannula systems and a variety of cutters.
The Sterallis Elite is also the only system with a hypersonic vitrectomy probe. The advent of valved trocars has improved the fluidics of vitrectomy by preventing aqueous reflux through the open cannula.
The surgeon may experience difficulty introducing instruments, such as the soft-tipped extrusion cannula, through the valved cannula. Techniques to overcome this difficulty include the push-pull technique or displacement of the valved leaflets. The stabilization of the fluid dynamics during surgery outweighs any difficulties, especially when complex pathology is present. Valved systems also help to stabilize IOP during surgery, minimizing the risks of intraoperative and postoperative maculopathy, choroidal detachment, and choroidal hemorrhage.
Patients who have undergone refractive cataract surgery with loss of lenticular material may benefit from the minimal refractive changes and enhanced visual rehabilitation following surgery with small-gauge trocar systems. One of the most important tools in the vitreoretinal surgery toolbox is the vitreous cutter. It allows safe and effective dissection of the hyaloid near the retina, membrane peeling, core vitrectomy, and vitreous biopsy.
Several factors have been identified that affect tractional forces in retina surgery, including cutting speed, distance from the retina, aspiration rate, and duty cycle. The increased cutter speeds minimize turbulence and may decrease peripheral traction and iatrogenic breaks. The latest cutter for this platform, the Ultravit, has also been designed with a bevelled tip and a larger cutting port opening, which facilitate higher aspiration rates and easier dissection of epiretinal membranes or when cutting close to the retina.
Recently, DORC International developed a new 2-dimensional cutter that allows up to 16, cuts per minute. This 2-dimensional cutting maximizes efficiency, and the reduced turbulence increases shaving safety. This technology is available in multiple gauges , , and gauge. This cutter, coupled with valve timing intelligence, enhances safety and control while shaving close to the retina.
This may represent a disadvantage when cutting close to the retinal surface. The new Steralis Elite cutter has a cut rate of 7, cuts per minute, which effectively becomes 15, cuts per minute while using a 2-dimensional cutting system. The most novel instrument regarding vitreous cutters is the new gauge hypersonic vitrectomy probe exclusively compatible with the Stellaris Elite Figure 2. This probe liquefies the vitreous instead of cutting it. This may provide a number of advantages compared with conventional pneumatic guillotine cutters because of its unique design features and mechanism of action.
This technology may change the way we approach retinal surgery, especially in complex cases with a highly adherent vitreous, such as in pediatric patients. Figure 2. A major technical hurdle has been the development of a fragmatome compatible with gauge and smaller cannula systems. The most widely available fragmatome is still gauge, and many surgeons prefer to open a gauge sclerotomy with the vitreoretinal blade to use the fragmatome.
However, we have found that a perpendicular gauge trocar incision allows for the placement of a gauge fragmatome in most cases. If difficulty is experienced during fragmatome introduction, opening the incision site with either the trocar blade or a gauge vitreoretinal blade can be considered. A variety of infusion cannula tips is currently available. In pseudophakic adults, we routinely use the 4-mm infusion tip.
However, in phakic patients, especially in the pediatric population, we routinely use 2. A wide array of surgical forceps choices are commercially available for different surgical needs. They can be used to perform the pinch-peel technique or can be coupled with a diamond-dusted membrane scrapers or loop. Most ILM forceps on the market today are asymmetrical and therefore the tip angle conforms to the retina only at the most distal area for better visualization while grasping tissue.
Serrated forceps are designed to manipulate heavy membranes. They are the most widely used forceps in complex cases of PVR or diabetic retinopathy. When maximum grip is needed, serrated forceps are an easy choice. Micro-textured grasping forceps Figure 3 , a variation of the serrated forceps, allow secure grasping of fibrous or adherent membranes while minimizing trauma to tissues.
They have become our forceps of choice in complex cases of diabetic retinopathy. Horizontal scissors are commonly used to cut retinal bands and tractional components close to the retinal surface. Angled scissors most commonly follow the contour of the eye to minimize retinal trauma during vitreoretinal interface manipulation.
Currently, some manufacturers have illuminated horizontal scissors that are particularly useful during bimanual surgery. Scissor illumination minimizes the need for chandelier placement. Vertical scissors are commonly used in the most complex proliferative cases with multiplane tractional bands. Vertical scissors may have a sharp anterior edge to optimize close dissection, tissue segmentation, and delamination techniques. One of the more challenging maneuvers associated with removal of the epiretinal membrane ERM and the ILM is safely creating an edge to lift the membrane prior to peeling.
Whether you use a pick, forceps, or a diamond-dusted membrane scraper, the goal is the same: to consistently produce a precise edge for rapid, complete peeling.
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