Hypersonic vitrectomy: a novel approach to vitreous removal

ABSTRACT

Introduction

Pars plana vitrectomy is the basis of modern retina surgery, and for the last 40 years, has been achieved using the pneumatic guillotine cutter. Recently, a new vitrectomy design has been developed: the hypersonic vitrector. This technology utilizes ultrasound energy to liquefy vitreous in contrast to the mechanical segmentation of vitreous strands that characterizes pneumatic cutters.

Areas covered

This review provides a history of the development of vitrectomy and summarizes the critical elements of effective and safe vitrectomy systems. The article will describe the novel hypersonic vitrectomy design, discuss what the initial pre-clinical and in-human studies tell us about its performance compared to standard pneumatic cutters, and considers its role in the future of retina surgery.

Expert opinion

Hypersonic vitrectomy is the first novel way to segment vitreous since the development of pneumatic guillotine cutters. It has the potential to make vitrectomy more efficient both by reducing operating times as well as enabling surgeons to remove silicone oil and retained lens material all with one instrument. With concurrent advancements in guillotine cutters, hypersonic vitrectomy has a high bar to clear to demonstrate advantages that would result in widespread adoption.

KEYWORDS:

• Hypersonic vitrectomy
• pars plana vitrectomy
• surgical innovation
• vitreoretinal surgery

Article highlights

• Hypersonic vitrectomy draws upon the principles of phacoemulsification and applies it to vitreous removal. Ultrasonic vitreous liquefication is achieved through high-frequency oscillation of a closed-tip needle with an open distal side port.

• Ex vivo and in vitro studies demonstrate that hypersonic vitrectomy creates small vitreous particles that reduces viscosity. This, along with 100% duty cycle, results higher fluid flow rates than pneumatic cutters

• Hypersonic vitrectomy may reduce vitreoretinal traction and decrease surgical time by achieving vitreous liquefication prior to aspiration into the needle.

• Histologic analyses of retinal tissue from eyes subjected to both hypersonic and pneumatic vitrectomy show post-operative inner-retinal vacuolization, but no macroscopic or microscopic differences between the two vitrectomy technologies. As such, hypersonic vitrectomy is thought to be as safe as pneumatic vitrectors at this time.

• Early clinical studies confirm overall efficacy of hypersonic vitrectomy in humans and generally positive surgeon experiences. Earlier generation hypersonic vitrectors appeared to be less effective than pneumatic cutters for removing dense vitreous hemorrhage or thick vitreous, as well as inducing posterior vitreous detachments. Evolution of probe design and function may help these situations.

• Potential areas where hypersonic vitrectomy may be uniquely advantageous over pneumatic cutters include simultaneous vitreous and lens particle aspiration, silicone oil removal, and the emulsification of fibrotic pre-retinal and sub-retinal membranes.

• Further study with hypersonic vitrectomy in the clinical setting is needed before it can be determined whether it will meet or exceed the performance of modern, refined pneumatic cutters.

Declaration of interest

S Garg has acted as a consultant for Allergan, American Academy of Ophthalmology, Apellis, Bausch + Lomb, Boehringer Ingelheim, Coherus, Johnson & Johnson, Kanaph and Merck Manuals and has received research support from American Academy of Ophthalmology, Apellis, Boehringer Ingelheim, Kodiak Biosciences, NGM Bio and Regeneron. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.