At Cincinnati Eye Institute, I am one of seven retinal surgeons who operate in one ambulatory surgery center (ASC) and various hospital-based facilities. All of us are quite busy and operate the typical surgical retinal case mix that includes diabetic retinopathy, epiretinal membrane (ERM) peeling, and retinal detachment. As an avid and early converter to smallgauge transconjunctival vitrectomy surgery since late 2004,my cases have evolved to be about 85% 25 gauge, 10% 20 gauge (usually complex cases requiring endoscopic visualization), and 5% 23 gauge (combined scleral buckle vitrectomy or select cases with fellow involvement). I heavily utilize 25-gauge disposable instrumentation and use GRIESHABER DSPs (Alcon Laboratories, Inc.) for almost all smallgauge forceps-based applications.The key advantages of GRIESHABER DSP instrumentation are predictability, reliability, and superior performance.

REUSABLE INSTRUMENTATION EXPERIENCE
In the past, the real world failure rate of reusable 25-gauge instrumentation ranged from anywhere between 10% and 50%. The damage was sometimes a catastrophically mangled tip, but other times the damage was more subtle with a grossly normal looking forceps that just did not grasp tissue adequately or more concerning, a forceps tip that grasped but did not let go.The failure rate was independent of the manufacturer and seemed at least somewhat related to specific operating facilities, the wear and tear of general handling, and the sterilization process.

Reusable instruments require a fairly complicated cleaning regimen—water to wash out the balanced salt solution, alcohol to wash out the water, and air to dry off the alcohol. Every now and again the instruments must be “milked,” which is a lubrication process to maintain peak performance.This entire process takes time, energy, manpower, and experience.Most importantly, the level of expertise required to maintain small-gauge ophthalmic instruments is not guaranteed in any OR, let alone a facility with lower vitreoretinal volume.

Particularly in hospital settings, without ophthalmic specific surgical teams,we had problems with reusables that ranged from the above mentioned failures to the instruments residing in an unspecified tray on an unspecified shelf where no one could locate them.All of this is negated with disposable instrumentation. With DSPs, the technicians simply open the sterile packaging and the single use instrument is ready to go. DSPs in this setting add a degree of confidence for the surgeon and, in fact, the entire surgical team. Everyone knows that the instrument will be available and will work perfectly and consistently every time.

SURGICAL TIMES AND SAFETY
There are surgeons in our group who still happily employ reusable instruments of all gauges including 25 gauge.We are also fortunate to have a skilled surgical team in our busy six operatory ASC whose expertise and experience makes this possible—and the case turnover is fairly comparable between those of us who use DSPs vs reusable instruments. If the time that it takes to clean reusable instruments and get them back in the tray translates to an instrument that works for the next case, reusables are a perfectly reasonable choice. If, on the other hand, the extra few minutes of turnover translates to being handed an instrument that is damaged, bent, or that simply performs suboptimally for the next case (recalling my up to 50% failure rate with reusables), DSPs are an excellent choice to maintain efficiency in the OR throughout the day.

The biggest impact I perceive from the GRIESHABER DSP forceps is on the efficiency and safety of the surgical procedure itself.The performance of these instruments is excellent,which is critical for efficiency and safety intraoperatively. For routine ERM and internal limiting membrane (ILM) peeling,my favorite instrument is the 25-gauge Asymmetric forceps (Figure 1).These forceps have a beautiful touch on the retina. I perform pinch peels for nearly all of my membrane peeling applications: right-handed for right eyes and left-handed for left eyes.Using the Asymmetric DSP ILM forceps, I simply go down to the retinal surface, grasp the membrane,and perform the peel. I rarely employ a scraper to start a routine membrane peel, and have not used a pik for many years.Prior to the availability of the DSPs, this was a hitor- miss proposition.The End-Grasping forceps have a similar superb touch on the retinal surface and perform similarly for my colleagues who prefer an end-grasping forceps profile.

Other useful additions to the DSP product line are heavy-duty MAXGrip (Figure 2) and DSP Serrated forceps (Figure 3; Alcon Laboratories, Inc.), both of which have phenomenal grabbing power. We had a case where a silicone plate haptic IOL had luxed into the vitreous cavity.Using the 25-gauge DSP Serrated forceps,we were able to lift it up, and take it right out of the eye. This can be notoriously difficult because silicone IOLs can be slippery and difficult to handle.The DSP Serrated forceps made short work of the case. In fact, these next generation “heavy lifting” forceps have played a substantial role in expanding the surgical indications for 25-gauge vitrectomy to include severe PVR as well as severe PDR. Both these pathologies may require stripping of very substantial fibrous epiretinal membranes.

The largest single factor that translates to safety is the predictability of the GRIESHABER DSPs.When a DSP is opened, the instrument performs the exact same way—the way it was designed to perform— every single time. The reduction in cumulative stress over a long busy OR day is noticeable to the surgeon and the OR staff. The OR staff at the Cincinnati Eye Institute strongly prefer DSPs because the day runs more smoothly without drama, stress, or instruments that fail.

PEARLS FOR SWITCHING TO DSPS
The best advice I can offer to surgeons who are considering switching from reusables to disposable instrumentation is that if he or she is happy with the performance and reliability of a type of instrument, there may be no need to switch. However, if reusables cause any level of stress that relates to reliability, predictability, or performance, disposables can truly make a difference.

At the Cincinnati Eye Institute and even more so at outlying hospital facilities, I have seen a palpable and worthwhile return on investment from the GRIESHABER DSP instrumentation.They have improved safety for my patients, improved OR efficiency, and have noticeably improved the quality of my OR day. Long live the DSP.

Christopher D. Riemann,MD, specializes in medical and surgical vitreoretinal diseases at the Cincinnati Eye Institute in Ohio. Dr. Riemann can be reached via email at criemann@cincinnatieye.com.