Year in Review: Surgical Retina

Reviewed by Pravin Dugel, MD, Charles Wykoff, MD, PhD, and Marco Zarbin, MD, PhD, FACS

Take-home: Two novel improvements of the last year have potential to make a long-lasting impact in retina surgery. 

Looking back at 2016, incremental improvements in devices are changing how retina surgeons approach and treat surgeries, said a group of experts.

For Charles Wykoff, MD, PhD, two novel improvements may not radically alter surgical approaches today, but will have a long-lasting impact down the road.

The EVA (DORC) vitrectomy device “has an exceptionally high cut rate because they've introduced something called the two-dimensional cutter (TDC),” said Dr. Wykoff, Retina Consultants of Houston, and Deputy-Chair of Ophthalmology, Houston Methodist Hospital. There may be more than 500,000 vitrectomy procedures performed yearly, but it is still a delicate procedure and machines that can allow for a safer and more precise surgery are welcome, Dr. Wykoff said.

“The innovation in the EVA is that there’s an extra hole in the body of the guillotine blade. It cuts going down and it cuts going up. Basically, the device has an 8,000 cut rate but an effective cut rate of about 16,000,” Dr. Wykoff explained.

He predicts “fluidics and the dynamics of surgery are going to continue to improve.”

Another advance still in its infancy but gaining momentum is Alcon’s NGENUITY, a heads-up three-dimensional display.

“There’s no question this has the potential to be a game-changer, and the first generation of a new era of surgical viewing,” Dr. Wykoff said. “Giving residents and fellows access to the identical view that the surgeon has will be excellent for teaching.”

It is “absolutely” going to create the “most excitement in the surgical field,” agreed Pravin Dugel, MD, Retina Consultants of Arizona, Phoenix. “Digitally-assisted vitrectomy surgery is where the field is heading.”

Marco A. Zarbin, MD, PhD, FACS, also agreed about the significance of the technology. “NGENUITY is a big deal from the standpoint of training and engaging the OR personnel,” said Dr. Zarbin, who is Chair, Institute of Ophthalmology & Visual Science, Rutgers New Jersey Medical School. He predicts more efficiencies with the machine and likened it to the introduction of the operating microscope-initially some naysayers thought the benefits were minimal, but eventually surgery like vitrectomy became possible because of the microscope.  

“The heads-up display moves surgeons away from the microscope and incrementally makes them less directly connected to the patient,” Dr. Zarbin said. “The hands are still manipulating instruments in the eye, but the surgeon is looking at a video screen. That creates an environment where it becomes somewhat easier to introduce robotics into the surgical field.”

While the idea of robotics during surgery is not novel, it is not currently a routine use in ophthalmology. Prof. Robert MacLaren, University of Oxford, has also investigated robotic epiretinal membrane surgery, but it is not yet mainstream.

“You can see how the heads-up display really lends itself to robotic surgery-surgeons have a very good view of what's going on inside the eye and probably feel a little more comfortable manipulating devices without looking directly through the microscope inside the eye,” Dr. Zarbin said. “Eventually, robotic surgery probably will enable us to do better and more precise intraocular surgery.”

To that end, Julia A. Haller, MD, ophthalmologist-in-chief, Wills Eye Hospital, Philadelphia, believes incremental changes to small-gauge surgery helped define 2016.

“We use 30-gauge needles for intraocular injections, but the challenge is to figure out better vitreolytics,” she said. Alternative methods to dissolve anomalous vitreous to (perhaps) liquefy it, for example, could be enhanced by smaller gauge instruments to remove it.

“But how small we can go will depend on how effectively we can modify what we’re removing,” Dr. Haller said.