Integrating New Tech Into the OR

This year, retina specialists will see a few big upgrades in their retina ORs. Newly integrated technology, a new vitrectomy machine, and a slew of novel tools and upgrades will hopefully lead to more efficient surgeries and better outcomes. Here, surgeons share what you can expect with the EVA NEXUS platform (Carl Zeiss Meditec/DORC), UNITY Vitreoretinal Cataract System (Alcon), or the Stellaris Elite (Bausch + Lomb).

THE EVA NEXUS PLATFORM

By Asheesh Tewari, MD

The field of vitreoretinal surgery is advancing rapidly, with technological innovations that enhance precision, efficiency, and patient safety. The EVA NEXUS platform (Carl Zeiss Meditec/DORC) exemplifies these advances, providing a state-of-the-art solution for vitreoretinal and combined phacovitrectomy surgeries. The acquisition of DORC by Carl Zeiss Meditec positions the EVA NEXUS for integration into the Zeiss Retina Workflow system.1 This integration has the potential to unify preoperative imaging, surgical planning, and intraoperative display of surgical parameters, creating a seamless and efficient surgical process. The EVA NEXUS itself also introduces new features designed to improve outcomes and optimize the surgical experience, including the following:

• The proprietary VacuFlow VTi technology is a dual-mode pump system that allows surgeons to switch between vacuum and flow mode. Flow mode (with 0.1 cc accuracy) can provide the precision and stability needed for shaving vitreous near a mobile retina, especially in cases of retinal detachment.
• Smart IOP is an infusion mode that maintains stable IOP throughout surgery. Smart IOP automatically compensates for anticipated pressure fluctuations, ensuring chamber stability and reducing the risk of pressure-related complications, such as choroidal detachments and hypotony. In addition, Smart IOP can help to minimize IOP spikes that can occur during surgery.
• The Inicio microinjection system, the first system approved for subretinal injections, delivers low-volume injections with ± 1 psi control, making it ideal for the administration of subretinal gene and cell-based therapies. Inicio is controlled by a footswitch and is compatible with multiple subretinal injection cannulas.
• The system includes the TDC Veloce vitrectome, which offers enhanced shaft stiffness, high-speed cutting (up to 20,000 cuts per minute), a universal cartridge, dual irrigation lines, and advanced fluidics. In addition, the ergonomic design of the Veloce cutter also reduces vibrations, improving surgeon comfort during prolonged procedures.

The EVA NEXUS platform sets a new benchmark in vitreoretinal and phacovitrectomy surgery by combining advanced fluidics, innovative subretinal injection capabilities, and enhanced usability. Designed with input from surgeons, it addresses the challenges of modern retinal procedures, optimizing safety, efficiency, and outcomes.

ALCON UNITY VCS

By S.K. Steven Houston III, MD

The UNITY Vitreoretinal Cataract System (VCS, Alcon) is set to release in 2025, offering a whole new platform, not just an upgrade from the Constellation system. Although it integrates much of the technologies from prior (IOP control, enhanced user interface), the new system offers significant workflow efficiencies such as increased cut rates, improved fluidics, and a host of new technologies. The improved fluid dynamics provide better surgeon control and enhances efficiency and safety, particularly over a mobile retina (eg, retinal detachment cases). New settings allow surgeons to adjust the fluidics on the fly.

On my first use of the new UNITY system, the improved 27-gauge performance stuck out significantly. For those who have yet to transition to 27-gauge instrumentation with the Constellation, the Unity VCS offers 27-gauge performance and efficiency that is on par with those we have come to expect with 25-gauge surgery. The fluidics are spot-on, and completing a core and peripheral vitrectomy with 27-gauge took the same amount of time as it does when using 25-gauge on the Constellation. Combined with enhanced stiffness and a suite of ancillary instruments (laser, internal limiting membrane forceps, etc), transition to 27-gauge with UNITY should be seamless.

The system does not include an auto-gas fill system, but pairs with the company’s newly released UNIFEYE gas delivery system, which integrates all components for gas delivery into a handheld, single-use gas device. This new system will improve workflows for this step and enhance safety and efficacy.

In addition to all the usual laser probe options, including curved and illuminated, the UNITY platform comes with a new tetraspot laser that allows for the simultaneous application of four laser spots (2 x 2 grid). Additionally, the laser pedal is now integrated into the primary foot pedal, allowing for more efficient transition from vitrectomy mode to laser. Overall, this new technology further improves surgery times, and combined with 27-gauge instrumentation, is ideal for challenging diabetic cases.

Although the UNITY is an entirely new platform built from the ground up, the machine is intuitive to use and will integrate into historic Constellation ORs with ease.

BAUSCH + LOMB STELLARIS ELITE

By Emmanuel Y. Chang, MD PhD FACS FASRS

My outpatient ambulatory surgery center has been using the Stellaris Elite (Bausch + Lomb) for years due to its ability to be use for both cataract and vitreoretinal surgery. In addition, the company allows for a customized surgeon vitrectomy pack, eliminating unused materials, providing significant pack costs savings, and improving revenue generation.

Other components of the Stellaris Elite platform that I find helpful during vitreoretinal surgery is the wireless pedal with separate pitch and yaw control and laser control integration. During lens fragmentation, I can control vacuum with pitch to hold the lens fragment and titrate the ultrasonic fragmentation power (using pulse per second mode) with the yaw. This dual control is also beneficial for complex diabetic dissections because I can control the aspiration with pitch and control the cutter speed based on the degree of pedal yaw.

Other welcome improvements to the platform were a redesigned cannula seal on valved trocars to prevent leakage, increased maximum vacuum to 660 mm Hg, and the addition of IOP control adaptive fluidics that provide incredible infusion stability down to 15 mm Hg when working at high vacuum. In addition, in 2025, Bausch + Lomb anticipates the release of 25,000 cut rates per minute, along with a beveled-tip vitrectomy cutter.

The Stellaris Elite offers different illumination filters to provide improved light safety and visualization with specific dyes, as well as a comprehensive portfolio of tools. A few favorites of mine are the Oshima dual 29-gauge torpedo chandeliers to avoid shadowing, a 45° directional illuminated laser probe, and an illuminated Chow membrane pick for bimanual dissection. Other unique instruments in the Bausch + Lomb line-up are aspirating laser probes, ultra-widefield light pipes, infusing/irrigating light pipes and chandeliers, and a broad range of forceps and scissors (vertical and horizontal curved). In particular, the BB forceps are popular for those who deal with trauma.

Bausch + Lomb is also working on the SeeLuma platform, a fully digital surgical visualization microscope in partnership with Munich Surgical Imaging, a subsidiary of Heidelberg Engineering. A fully digital system with digital binoculars can offer an augmented-reality surgical view through the oculars such as real-time OCT overlay and other image analysis.

Lastly, the company has continued to develop their Eyetelligence software platform. For anterior segment surgeons, it incorporates user applications specifically designed for optometrists/referring doctors and patients to communicate directly with the surgeon and provide IOL lens calculation and selection during the day of surgery. For the posterior segment, the software can track the total operating time, infusion fluid flow, average IOP, laser energy used, and other parameters to offer insights on surgical performance and compare your performance with that of global anonymized peers.

1. Carl Zeiss Meditec AG completes acquisition of Dutch Ophthalmic Research Center (D.O.R.C.); companies unite to shape ophthalmology market [press release]. Carl Zeiss Meditec. April 4, 2024. Accessed December 19, 2024. www.zeiss.com/meditec-ag/en/media-news/press-releases/2024/acquisition-dutch-ophthalmic-research-center.html