Reusable or Disposable Instruments?
Newer surgical techniques can dictate the choice.
BY JERRY HELZNER, SENIOR EDITOR

© ARELLANO/CUSTOM MEDICAL STOCK PHOTO

A retinal surgeon is preparing to perform 25-gauge vitrectomy. She can choose to use reusable end-grasping forceps and vertical scissors for the procedure, or the same instruments in single-use disposable form. She chooses the disposable instruments.

A cataract surgeon is preparing to perform small-incision phaco. He can choose a $2,000 reusable diamond knife or a $22 disposable metal blade. His choice is the more expensive, but sharper diamond knife.

Another cataract surgeon has to retrieve pieces of a broken IOL that have dropped into the vitreous cavity. He uses what can best be described as a "semi-disposable" tool that has a reusable handpiece and a disposable net at the tip. Employing this instrument allows him to fish out the lens pieces and continue the procedure.

These examples serve to highlight the fact that as newer surgical techniques achieve acceptance, instruments that are best suited to employ these techniques most effectively are also finding favor. This article will examine recent trends affecting the use of disposable, reusable and semi-disposable instruments in ophthalmic surgery.

Disposables are Suited for 25-Gauge

Probably the most dramatic example of a new line of instruments being suited to a new surgical technique is the 2003 introduction of the Grieshaber Revolution DSP line of single-use instruments (Alcon, Fort Worth, Texas) for vitreoretinal surgery. While the Grieshaber DSP line was originally developed to enable surgeons to better control the instrument tip through 360° rotatability and to avoid cross-contamination from infectious particles that can survive autoclaving, it has proved to be perfectly suited for use in increasingly popular, less-invasive 25-gauge vitrectomy. The numbers bear this out. Sales of the DSP disposable instrument category doubled in the past year.

	Sales have doubled in the past year for Alcon's Grieshaber Revolution DSP disposable instrument category. The end-grasping forceps pictured above is used in vitreoretinal surgery.

"The increasing use of 25-gauge systems is changing the way we think about disposable instruments," says Julia A. Haller, M.D., of the Wilmer Eye Institute at Johns Hopkins University. "Because the instruments we use in 25-gauge systems are small and fragile, the reusables tend to break more easily, are difficult to clean and expensive to repair. It's actually cost-effective to use disposables."

The Grieshaber Revolution DSP line initially consisted of an end-grasping forceps, a vertical scissors and a fiber-optics forceps. More recently, a 25-gauge curved scissors and 20- and 25-gauge Internal Limiting Membrane (ILM) forceps have been added to the range of DSP products.

"With DSP, you don't have to worry about sterilizing the instrument, breaking it or bending the tip so that it can't be used," says Merlin Hall, product manager, vitreoretinal marketing, Alcon. "The DSP costs approximately 5% of the cost of the reusable product and is brand new every time."

In an effort to retain its leadership in this category over competitors such as Synergetics (St. Charles, Mo.), Alcon expects to soon launch its entire range of DSP instruments with reusable handles and disposable tips.

"We will be offering surgeons three types of handle choices as opposed to the one type of handle that is now available with our DSP instruments," says Hall. "Our surveys show that only about 15% of vitreoretinal surgeons are currently using disposable instruments, so we believe there is a great opportunity for growth here."

	Surgeons are finding diamond knives superior to disposable metal blades for small-incision surgery. Pictured above is an Accutome diamond knife. An assortment of the company's Mani line of metal blades are pictured on the bottom.

A Return to Diamond Knives

If the emergence of disposable instruments for vitrectomy represents the best example of disposables taking the place of reusables, the popularity of diamond knives for small-incision cataract surgery may represent the best example of a reusable product overcoming a disposable one.

"With surgeons moving to smaller incisions, they want to use the sharpest blades that produce the cleanest incisions," says Jim O'Connor, marketing manager for Accutome (Malvern, Pa.). "Dr. [Howard] Fine, one of the world's most respected cataract surgeons, recently held a seminar in which he emphasized the importance of using diamond blades."

O'Connor says that the danger of damaging an expensive diamond blade can virtually be eliminated through proper care and cleaning.

John Bee, president of Rhein Medical (Tampa, Fla.) says he is also seeing increased preference for his company's diamond blades, which range in price from $1,000 to $3,800. Rhein also sells packs of single-use stainless steel blades, at a price that works out to about $22 per blade.

"Part of the resurgence we're seeing in diamond blades has been driven by our new blade-cleaning system, which helps keep the delicate cutting edge from being damaged," says Bee. "Though the initial cost of the diamond blade is much higher, it can be the economic choice if cared for correctly."

With the exception of the diamond blades, Bee sees the popularity of disposables increasing across his company's product offerings, including cannulas and cystotomes.

"There is a trend toward disposables because single-use products reduce the risk of cross-contamination, "stick" injuries caused by blade cleaning and endophthalmitis," notes Bee. "Hospitals are very active in driving this trend."

Rhein offers "resposable" instruments with replaceable tips, such as this "safety net" for retrieving IOLs that drop into the vitreous cavity.

Semi-Disposables Appear

Rhein has also been a pioneer in developing several new specialty instruments that have reusable handles and replaceable tips. Some of these instruments were initially developed by surgeons seeking a better way to perform procedures or deal with problems that can occur during surgery.

One of these instruments is the Utrata Foldable Lens Extraction System, developed in coordination with Peter J. Utrata, M.D. It is designed to safely remove any silicone foldable lens through a small incision without having to enlarge the incision. It features a snare wire that is looped around a foldable lens and then retracted to slice the lens into two or more pieces. The pieces can then be extracted with a special retrieval forceps that is part of the system. The snare wire is replaceable.

Rhein also offers a pupil dilator with disposable material used to place pressure on the iris, and a system with disposable netting to retrieve fragments of lenses that drop into the vitreous cavity.

Bee says that the company's line of semi-disposables (sometimes called "resposables") will continue to expand as new ideas come from surgeons and the company internally develops products of its own.

Also in the area of innovation, Oasis Medical (Glendora, Calif.), which produces a range of ophthalmic disposables, has recently developed its Form Fit Hydrogel Intracanalicular Plug, a one-size-fits-all punctum plug that expands to fit every patient when it interacts with tear film. The Form Fit Plug is sterile and comes pre-loaded on a disposable inserter.

	Alcon will soon introduce its DSP line with reusable handles and disposable tips.

Disposables and LASIK

The major development involving disposables and LASIK is the increasing acceptance of IntraLase with its single-use disposable patient interface that immobilizes the eye and flattens the cornea so that the IntraLase FS laser can cut the corneal flap. The patient interface also serves as a counting device that enables IntraLase to keep track of procedure volume for each practice that uses its technology.

Practices that use IntraLase have eliminated the need for the reusable microkeratome, but practices that have not adopted IntraLase can purchase a microkeratome with a disposable head and blade. The single-use microkeratome head was pioneered by Moria.

"Using a disposable microkeratome head and blade assures sterility and eliminates re-assembly of the head," says Brian Will, M.D., of Will Vision and Laser Centers, Vancouver, Wash. "The disposable head adds costs to the procedure but it takes away the risk of infection and reduces the chance of mistakes that can be caused if a reusable microkeratome head isn't re-assembled correctly."

Dr. Will says LASIK surgeons tend to re-use disposable cannulas but he notes that they are running the risk of inducing diffuse lamellar keratitis (DLK) if they sterilize disposable cannulas using steam and then re-use them on additional patients.

"If you intend to re-use a disposable cannula, you should use a dry heat sterilizer, but as a safety issue I discourage the re-use of any disposables," advises Dr. Will.

Ancillary Disposables

Though this article is primarily concerned with trends in reusable, disposable and semi-disposable instruments, it is important to note that companies have made refractive, cataract and vitreoretinal surgery easier by providing all of the disposables that a surgeon requires for a single procedure in one convenient package.

"The surgeon gives us a list of what he or she wants in the package and we provide all the disposables for that procedure in one of our CustomPaks," says Merlin Hall of Alcon.

Practices that use pre-packaged disposables say that ordering in this format facilitates inventory control and enables each surgeon to have all the disposables he or she needs for a procedure conveniently at hand.

Given that advances in such areas as polymer technology now make it possible to produce precision-quality ophthalmic instruments in cost-effective disposable forms, surgeons should soon expect to see more instances in which they will have the option of choosing between a disposable and a reusable instrument designed for the same purpose. Most surgeons will see a range of choices as a good thing.