Transition to a novel advanced integrated vitrectomy platform: comparison of the surgical impact of moving from the Accurus vitrectomy platform to the Constellation Vision System for microincisional vitrectomy surgery.

Rapid advances in surgical technology have occurred since the first automated vitrectomy was performed by Machemer in 1971.1,2 From 1971 until 2012, instruments have moved from separate systems for vitrectomy cutting, illumination, air/fluid exchange, silicone oil injection, automated scissors/forceps, and operative laser photocoagulation toward integrated platforms that include multiple technologies.3–5 A major advance in technology occurred with the introduction of the Accurus-integrated platform in 1997 (Alcon Surgical, Fort Worth, TX, USA). This platform achieved enhanced vitrectomy cutter performance, improved surgical fluidics, automated silicone oil infusion, and incorporated a posterior segment fragmatome and an anterior segment phacoemulsification capability. The Accurus platform rapidly became the standard within the United States and internationally. By 2008 the Accurus platform was present in over 90% of ophthalmologic operating rooms in the United States, including both hospital and ambulatory care surgical centers. The Accurus platform was characterized by an advanced cutter design, increased cutting rates to 2500 cuts per minute, gas-forced fluid infusion, dual halogen light sources, and software parameters that were established to maximize cutter efficiency at very high cut rates. At the Bascom Palmer Eye Institute, Anne Bates Leach Eye Hospital (BPEI/ABLEH), the Accurus platform became the standard vitrectomy console from 1997 to 2008. The Vitreoretinal Surgical Service at the BPEI had extensive interest in improving surgical platforms and techniques for vitreoretinal surgery and actively pursued evaluation and acquisition of the next generation vitrectomy platform. The Constellation Vision System (Alcon Surgical) was defined by a marked advance in cutter probe design specifically for micro-incisional vitrectomy surgery (MIVS), incorporating 23- and 25-gauge vitrectomy, markedly increased cutting rates to 5000 cuts per minute (enabled by elimination of spring technology to re-open the cutter after closure); integrated quadruple xenon light sources; had radiofrequency identification (RFID) recognition technology for identifying the cutter, light pipe, and endolaser probes; improved cassette design to eliminate loss of infusion fluidics; integrated a 532 nm solid state disc laser; and had torsional anterior segment phacoemulsification. This next generation platform addressed many concerns for instrument limitation and fluidic compromise associated with very high cut rates, while incorporating features that had previously required independent stand-alone systems for use in complex vitrectomy surgery. Further, specific attention was given to the enhanced safety features and targeted platform improvements that were designed to increase operating room efficiency while improving patient safety; these were attractive to our hospital teams and hospital administration. Prior to evaluation in this study, a transition period was established to educate our hospital teams, place the Constellation, establish a disposable supply support, and assist our vitreoretinal surgeons. This transition period utilized heavy educational support from the Alcon surgical support team and from in-house vitreoretinal surgeons aimed at supporting our hospital teams, with strong focus on our OR scrub teams and our OR circulating nursing teams. This study was a follow-up to a pre-implementation review document that hypothesized reduction in OR turnover times that would enable increased surgical volume per vitreoretinal surgical room per day. In this study we compared two time periods: one in which the Accurus platform was utilized exclusively and one in which the Constellation platform was utilized exclusively. We evaluated a 12-month time period to better minimize potential case mix bias or transition bias and to capture a significant case volume for analysis. Use of the University of Miami electronic health record enabled broad data capture for evaluation of case volume per day, surgical room time per case, and surgical procedure time per case. Data sets were evaluated blinded to the platform utilized for both the Accurus and Constellation Vision System. These data provide a foundation for evaluating the selection of novel surgical systems for the ophthalmic hospital or ambulatory surgical center and delineate the impact of transition for critical technology required for vitrectomy surgery in the 21st century.