As you know, vitreoretinal surgery frequently involves the use of numerous, complex surgical instruments. In the past, using separate devices to manage each function created a host of practical problems. If a patient also needed cataract surgery, it was usually scheduled at another time to avoid even more instrument management problems.

Today, cutting edge versions of all these instruments have been combined into a single, easy-to-use tool: the Accurus Multifunction Surgical System from Alcon. Originally designed for comprehensive, single-instrument vitreoretinal surgery, the Accurus now is available in a model that incorporates Alcon's popular Legacy ultrasonic phaco system.

Solving problem, meeting needs

According to Alcon, the Accurus was originally designed with four principles in mind:

�         System integration. The vitreoretinal system (still available without ultrasound) integrates all these functions:

o       digital infusion pressure control

o       fluid/air exchange

o       viscous fluid control

o       fragmentation

o       vitrectomy cutting

o       illumination

o       diathermy

o       precise vacuum control

o       scissors/forceps function.

You and your surgical team control all of these functions through a single console, using the touchscreen, footswitch and/or remote control. The design of the Accurus minimizes tubing and wiring.

�         Gold standard performance. Every Accurus function uses best-in-class instruments and standards.

�         Platform design. Five microprocessors and specially created software use real-time processing to provide dedicated, highly responsive management of every function. This design ensures that a problem in one system won't crash the other systems. (At the same time, parallel processing software architecture runs the system as a unit and monitors overall operation and system safety.) System enhancements can be made separately, without the need to purchase new hardware.

�         Ease of use. The Accurus was designed to be user-friendly and intuitive for both the surgeon and the nursing staff:

o       The Accurus prompts and guides the user during setup. In addition to providing on-screen reminders and warnings, each connection location is illuminated in turn to ensure that all connections are correct.

o       The Accurus touchscreen is designed to be simple and easy to use.

o       Touching the Test icon causes the Accurus to self-test and prime itself for use.

o       During surgery, LEDs indicate which connections are active, and on-screen prompts point out potential problems ranging from unsafe settings to poor connections.

o       The system provides 200 memory locations for surgeons to store preset parameter values, helping to simplify and speed setup. During surgery, scrubs or nurses can use the remote to change to different memory presets at your request.

o       Alcon provides comprehensive product support and field service. (You'll never need to return the instrument to Alcon for servicing.)

Fluidics

The Accurus uses a Vented Gas Forced Infusion system (VGFI) with digitally controlled air venting to provide nearly instantaneous IOP adjustment. (You don't have to raise and lower an IV pole.) The Accurus also features a microprocessor-controlled venturi vacuum aspiration system (rather than a peristaltic pump). The vacuum system doesn't use filters, which tend to reduce performance.

Other features include:

�         Two dedicated vacuum ports eliminate the need for a stopcock.

�         The system can rapidly adjust IOP to a preset value up to 120 mm Hg (a programmable tamponade).

�         Because the Accurus uses dedicated real-time processing to control vacuum and flow, response time to footswitch commands is consistently less than 25 milliseconds. (Serial processing can sometimes take two or three times as long to respond.)

�         The footpedal lets you trigger a 50 microliter reflux to release materials that inadvertently enter the aspiration port.

�         The aspiration system was designed to eliminate regurgitation and residual vacuum.

�         Fluids are automatically transferred to a self-sealing 500-cc biocontainment collection bag with no interruption of vacuum (a feature unique to the Accurus).

Probe options

The Accurus offers two state-of-the-art surgical probes:

�         The Accurus. This is an axial (guillotine-style) reciprocating probe with variable cutting speed up to 800 cuts per minute. It features a long cannula (for myopic eyes), ergonomic handle design, and quieter operation than many other probes of this type.

�         The InnoVit. The InnoVit radial oscillating probe can achieve a speed of 1,200 cuts per minute, because it uses a second air pressure line to reopen the port after cutting (instead of a spring). Other features include:

o       The cutter rotates less than 180�, eliminating spooling and causing less turbulence and fluttering in the vicinity of the port. (Surgeons report that this makes it possible to use very low suction settings during surgery, so the probe can be used very close to retinal tissue.)

o       Microprocessor-controlled cutting intervals result in improved flow rates and cutting at high speeds.

o       The pneumatically powered probe is much lighter than electrically-powered high-speed probes.

o       Because the probe is designed for single use, autoclaving isn't required.

Pravin Dugel, M.D., of Phoenix Ariz., says, "The main reason our surgery center, the Spectra Eye Institute, chose the Accurus was the InnoVit probe. The trend in vitreoretinal surgery today is toward removing as much vitreous as possible at high speed, which minimizes the chance of a tear. The InnoVit probe is very fast, very smooth and very accurate. It controls flow very well."

Both probes have the port located closer to the distal end than traditional probes. They also feature a tactile indicator on the handle so you know the orientation of the port.

Additional features and benefits

Other advantages of the Accurus system include:

�         Fragmentation. The Accurus fragmentation handpiece is a lightweight, four-crystal design that gives you digital control of the ultrasound signal. You can use ultrasound in proportional, fixed or momentary modes. (Pulsed fragmentation is available in all of these modes.)
Dr. Dugel uses proportional fragmentation for lensectomy. "With a traditional machine, you use suction to hold the lens material and then trigger a fragmentation burst which blows the lens material away. Then you have to go and chase it. The Accurus uses suction to hold the piece, but fragmentation starts gradually, so it doesn't spit out the lens material."
Needles are titanium, 20-gauge, and designed to minimize clogging and heating, while maximizing energy transmission.

�         Diathermy. A bipolar brush and probe are available with a choice of handpieces. (Global diathermy can be used at any time during the surgical procedure.)

�         Silicone oil use. The Accurus's Viscous Fluid Controller (VFC) provides digital, proportional control of silicone oil injection and removal, minimizing any chance of overfill or unexpected IOP variations. In addition:

o       A The footswitch controls injection pressure up to 80 psi and extraction vacuum up to 600 mm Hg.

o       A The vacuum system for removal of silicone oil is independent from the vitrectomy vacuum line and cassette, so coating of the tubing is no longer a problem.

o       A The VFC can be used with 1,000 cs or 5,000 cs silicone.

These features allow injection of silicone oil and simultaneous fluid extrusion without an intermediate air exchange, if you prefer.

�         Automated microscissors and forceps. According to Alcon, the Accurus is the first system to work with the Grieshaber Membrane Peeler Cutter (MPC), a state-of-the-art reusable, multicut, vertical scissors. The MPC is powered by the Accurus' electrical supply, so running out of battery power isn't a problem.
In addition to traditional manual scissors and forceps, a single-use, sterile, disposable, pneumatic microscissors or forceps tip can be attached to the Accurus scissors handpiece. Because the closing/opening action is automated, you can guide and hold the tool steady without having to apply manual pressure to operate the mechanism.

Scissors (or forceps) operate in several modes:

o       proportional mode (the footswitch controls the opening and closing of the blades)

o       multiple cut mode (the footswitch activates the scissors at a preset, adjustable cutting rate)

o       mono cut mode (the footswitch triggers a single cut).

Other advantages of this system include:

o       A Multiple cut mode can be accompanied by vacuum.

o       A You can adjust the amount of pressure exerted to close and open the scissors or forceps.

o       A The Accurus works with a wide range of instruments, including Alcon MicroScissors and Grieshaber Sutherland scissors and forceps.

�         Illumination. The Accurus uses halogen light, with frequencies filtered to optimize the visible spectrum and minimize the delivery of damaging energy to the retina. Also:

o       The Accurus features two independently controlled illumination ports, allowing the use of multiple light sources.

o       The Accurus works with a wide selection of accessories from Alcon, Grieshaber and Infinitech.

Available with Legacy ultrasonics

The newest model of the Accurus -- the 600DS Multifunction Surgical System -- incorporates Alcon's popular Legacy ultrasonics system. (Existing Accurus systems can be upgraded to the 600DS.) Features include Constant Admittance Tuning, which maintains constant frequency despite changes in cataract density as you work, and three phaco modes: fixed, linear and pulsed.

The new Accurus is compatible with the instruments developed for use with the Legacy, including advanced technology tips such as Microtips, ABS standard, ABS Kelman and Flared ABS tip technologies.

Ron Salvitti, M.D., of Pittsburgh, Pa., has been using the 600DS for about 2 years. "Patients with vitrectomies usually need cataract surgery within 2 years, so it makes sense to do both procedures at the same time. The Accurus makes this easy and cost effective. I use multiple techniques on both the Legacy and the Accurus, with little or no learning curve -- and no change in technique -- when I switch to the Accurus."

Covering all the bases

Russ Finlay, vitreoretinal instrumentation product manager at Alcon comments, "We've been in the vitrectomy field for a long time. We work hard to continue improving the capabilities of our instruments, and we offer everything related to this type of surgery -- expansile gases, solutions, handpieces and so forth -- not just the instruments themselves. We'd like to be thought of as the 'vitreoretinal source.' Our constant upgrading of the Accurus is just one example of that dedication."

Dr. Dugel agrees. "The Accurus is a first-class machine. It's a total package."

For more information about the Accurus, contact Alcon at (800) 862-5266.

Are you aware of new products or technology that have made (or are likely to make) a significant difference in practice? Contact Christopher Kent at kentcx@boucher1.com to find out about possible coverage in a future issue.