Supplement to

March 2009

Clinical Experience With the

CONSTELLATION
Vision System
Vitreoretinal surgeons discuss new features
and concepts in vitreoretinal surgery.

Sponsored by Alcon Laboratories, Inc.

CLINICAL EXPERIENCE WITH THE CONSTELLATION VISION SYSTEM

Introduction
The CONSTELLATION Vision System (Alcon Laboratories, Inc., Fort Worth, TX) is an integrated vitreoreti-
nal system that not only has advanced cutting capabilities, but also highly efficient flow and intraocular
pressure control, an embedded 532 nm thin-disc laser system, and intelligent efficiency features that
improve every aspect of a vitrectomy procedure.
The development of this system has been a long time in the making. Along with Alcon, the physicians
who have been involved with the design of the CONSTELLATION Vision System have put a great deal of
thought into the technology and how it would respond to many different surgical scenarios.
This supplement to Retina Today offers insight directly from those closest to the development of the CONSTELLATION
system. Kirk Packo, MD, discusses the new cutter on the system and explains the importance of duty cycle to improved
patient outcomes and efficient vitreoretinal surgery. Steve Charles, MD, explains how the flow control on the cutter func-
tions for more efficient cutting. Roger Novack, MD, outlines how this new system has improved on illumination for small-
gauge surgery while minimizing risks for light toxicity. David Dyer, MD, provides his clinical experience with the IOP control
and fluidics on the CONSTELLATION system. Timothy G. Murray, MD, FACS, describes the new, highly efficient embedded
532 nm thin-disc PUREPOINT laser and finally, Pravin U. Dugel, MD, defines surgical efficiency and explains how the
V-LOCITY Efficiency Components work in an integrated manner on the system to increase surgeon control of the system
and make the surgical procedure easier. We also include panel discussions on clinical experience with the CONSTELLATION
system featuring David Boyer, MD; Dr. Dugel; Peter K. Kaiser, MD; Dr. Murray; and Stanislao Rizzo, MD.
As vitreoretinal surgery has evolved, there has been an increased focus on not only the quality of patient care, but also on
surgical efficiency. Many of us remember the days when four cases would take up an entire day on our surgical schedule.
The expanding pathology that is amenable to surgical manipulation, however, has changed the volume of our cases and in
turn, our procedures in the OR. The surgeons who have presented articles in this supplement all have asked the question,
“Wouldn’t it be great if we could be even more efficient?”
The integrated components of the CONSTELLATION Vision System improve our surgical capabilities and allow us to be
more efficient surgeons in the care of our patients. Elegant and effective surgeons are those who are most efficient in their
surgical maneuvers, and the CONSTELLATION system affords us the opportunity to be the best we can be for those who
put their vision in our hands.

-Allen C. Ho, MD
Chief Medical Editor, Retina Today

Contents
3 HIGH-SPEED CUTTING AND 9 INTEGRATED INFUSION
DUTY CYCLE CONTROL PRESSURE AND IOP CONTROL
By Kirk H. Packo, MD By David S. Dyer, MD

5 FLOW CONTROL WITH 11 CLINICAL EXPERIENCE WITH

THE CONSTELLATION THE PUREPOINT LASER
By Steve Charles, MD By Timothy G. Murray, MD, MBA, FACS

7 ADVANCES IN ILLUMINATION 13 SURGICAL EFFICIENCIES ON

By Roger Novack, MD, PhD, FACS THE CONSTELLATION VISION SYSTEM
By Pravin U. Dugel, MD

2 I SUPPLEMENT TO RETINA TODAY I MARCH 2009

 CLINICAL EXPERIENCE WITH THE CONSTELLATION VISION SYSTEM

High-speed Cutting
and Duty Cycle Control
BY KIRK H. PACKO, MD

T
he main goal of every retina surgeon when
removing vitreous is to not tear the retina.
Vitrectomy and vitreous loss are not synony-
mous. There are two scenarios in removing vit- “Vitrectomy and vitreous loss
reous: in the first, the surgery is controlled and the
result is an eye with less vitreous; in the second, the sur-
are not synonymous.”
gery in uncontrolled and the result is a torn retina.
There are four principles to removing vitreous in a
controlled fashion. First, do not pull the vitreous too
close to the probe. Second, do not pull vitreous too far time. A 50/50 cycle is when the port is open in direct
up the probe. Third, remove the vitreous in tiny pieces. proportion to the time that it is closed.
Fourth, use as low a flow as possible. Regardless of the The standard probes that have been available to us
cut rate, vacuum, or duty cycle selected, it is important include an electric probe (ie, MILLENNIUM, Bausch &
to maintain these four principles to avoid putting trac- Lomb, Rochester, NY), which operates on a constant
tion on the retina and cutting unintentionally. duty cycle, and a spring-pneumatic probe (ie,
ACCURUS, Alcon Laboratories, Inc., Fort Worth, TX),
THE RELATIONSHIP OF DUTY CYCLE AND which has a variable duty cycle. At a slower cut rate, the
CUTTING SPEED electric probe slows the time between the time port
Poiseuille’s law explains the relationship between vis- open and port closed, but the ratio between the two is
cosity and length, but it only addresses a tube that is equal, which means that the flow at fast cut rates vs
open all the time. In vitreoretinal surgery, we are operat- high cut rates is the same. The only thing that changes
ing with a tube that is opening and closing continuous- between low and high cut rates is that the size of the
ly. Duty cycle is essentially the ratio of open time to pieces taken at higher rates is smaller. The pneumatic
total time. A closed cycle is when the port is mainly probe with the spring return has a variable duty cycle,
closed and open for a short time, and conversely, an meaning that the dwell time between each cut decreas-
open cycle is when the port is open for most of the es at higher cut rates. The relationships between duty

Figure 1. The relationship between duty cycle flow rates and Figure 2. A slower cutting rate actually results in tissue
cut rates. moving more quickly to the port.

MARCH 2009 I SUPPLEMENT TO RETINA TODAY I 3

CLINICAL EXPERIENCE WITH THE CONSTELLATION VISION SYSTEM

Figure 3. Ultraslow motion shows the stretch of the vitreous Figure 4. There is far more turbulence in the frame showing
fiber. 1000 cpm than in the frame showing 2500 cpm.

Figure 5. The spring-release mechanism slows cutting speed Figure 6. The new pneumatic probe eliminates the spring-
in the earlier pneumatic probe design. release mechanism and uses pulsed air to control duty cycle.

cycle, flow rates, and cut rates are seen in Figure 1. frame assessment. At 5 cc’s of isotonic flow, we looked
at 1000 cpm vs 2500 cpm with the vacuum at various
NEW PNEUMATIC PROBE levels to ensure constant flow. In fact, we discovered
The CONSTELLATION Vision System (Alcon that tissue was moving twice as quickly into the port at
Laboratories, Inc.), has a newly designed ULTRAVIT the slower cut rate (Figure 2). The action is all at the
pneumatic probe that operates on a variable duty cycle, port—there is a significant difference in speed and the
but adds the ability to control the bias of the cycle to way that material is pulled.
keep it primarily open or primarily closed. Flow patterns are much more complex in real vitre-
Although it has been a goal for many years to create ous. Individual vitreous fibers are pulled “on stretch” to
faster probes, it has been established that this is only the port. When cutting occurs, the fiber snaps away,
significant for pneumatic probes because, as earlier stat- redistributing the remaining fibers. At ultraslow motion,
ed, the electric probes merely cut smaller pieces at high- the stretch of the vitreous fiber is apparent (Figure 3).
er speeds with no change in flow. The vitreous cuts cleanly, allowing remaining vitreous to
Viewing the movement of particles in slow motion to snap away. When looking in slow motion with the same
the probe at various cut rates allowed us to see how parameters as in the isotonic model (1000 cpm vs 2500,
fast tissue is moving to the probe and make a frame-by- same flow and vacuum) there is far more turbulence in

4 I SUPPLEMENT TO RETINA TODAY I MARCH 2009

 CLINICAL EXPERIENCE WITH THE CONSTELLATION VISION SYSTEM

FLOW CONTROL WITH THE CONSTELLATION

By Steve Charles, MD

The design of the new CONSTELLATION Vision System (Alcon Laboratories, Inc., Fort Worth, TX) expands on the
ACCURUS Surgical Systems (Alcon Laboratories, Inc.) integration theme. The CONSTELLATION system builds on the
ACCURUS platform and has improved cutting, better fluidics, an advanced illumination system, and enhanced tool perform-
ance. Additional significant improvements on the CONSTELLATION system include new component technologies, an inte-
grated laser system (PUREPOINT, Alcon Laboratories, Inc.), and efficiency components (V-LOCITY, Alcon Laboratories, Inc.).
The aspiration control system not only provides control of vacuum, cutting, and variable duty cycle, but also has flow-
sensing capabilities. Thus, the surgeon can operate in a true flow mode or flow limiting mode. There is a distinct difference
when you can push the foot pedal down and know that flow can be controlled to an exact level through the port. Flow
control utilizes a digital feedback loop and an actual flow sensor.

Flow Limiting
Peristaltic pumps produce pulsatile vacuum and work without a feedback loop or flow sensing capabilities. They produce
slower vacuum rise times as well as footpedal-commanded flow and/or vacuum decrease. The CONSTELLATION system
utilizes a peristaltic pump and allows for 3-D cutting and proportional vacuum control. Additionally, the CONSTELLATION
can utilize both flow limiting mechanisms and true flow control.
In addition to flow control the 5000 cpm high-speed cutting rate of the ULTRAVIT probe (Alcon Laboratories, Inc.) cou-
pled with variable duty cycle control produces port-based flow limiting, which I have presented numerous times as a vehicle
to decrease pulsatile vitreoretinal traction on both detached and attached retina.

Steve Charles, MD, is the founder of the Charles Retina Institute in Memphis, and is a member of the Retina
Today Editorial Board. He is a paid consultant for Alcon Laboratories, Inc. Dr. Charles can be reached at
+1 901 767 4499; or via e-mail: [email protected].

the frame showing 1000 cpm than in the frame showing because of the ability to adjust duty cycle for a given cut
2500 cpm (Figure 4). There is a large amount of diffuse rate and as a result, the surgeon has the ability to operate
movement around the port at the slower cut rate, while in any location efficiently.
the vitreous movement is primarily at the port at the
faster cut rate. SUMMARY
Low cutting rates on a standard pneumatic probe Duty cycle is an innovation that allows surgeons to
result in a lengthy dwell open time for the port, resulting control flow. The open-bias duty cycle, like our current
in high flow. If you cut at a higher rate, however, you are ACCURUS probe, decreases flow with increasing cut
essentially stealing from the dwell time. The cutting time rate. The closed-bias duty cycle on the ULTRAVIT cut-
is the same, but the flow is even lower. Eventually, the ter is new technology that allows surgeons to increase
machine will cap out as flow continues to decrease, mini- flow with increasing cut rate; once the cut rates reach
mizing the ability to cut effectively at higher speeds. high levels, such as 5000 cpm, the cut and flow become
The new pneumatic cutter design removes the spring sinusoidal. Duty cycle is an inseparable parameter from
release (Figure 5) and replaces it with a pulse mecha- cut rate and the improvements to the ULTRAVIT cutter
nism, which operates by using air to pulse the port have increased surgeons’ capability to efficiently control
open and pulse the port closed (Figure 6). The most flow during surgery. ■
important result of this new design is that dwell time is
adjustable because either side of the pulse equation is Kirk H. Packo, MD, is Professor and Chairman
changeable. of Ophthalmology at Rush Medical College,
The advantages to the ULTRAVIT probe include the Assistant Professor and Chairman of
ability to cut at much higher rates and that duty cycles Ophthalmology at Illinois Eye and Ear Infirmary
are easily controllable. The surgeon can keep the port in Chicago, and a member of the Retina Today
biased open, biased closed, or even biased. Editorial Board. He is a consultant for Alcon Laboratories, Inc. Dr.
The working area with the ULTRAVIT probe is larger Packo can be reached via e-mail at [email protected].

MARCH 2009 I SUPPLEMENT TO RETINA TODAY I 5

CLINICAL EXPERIENCE WITH THE CONSTELLATION VISION SYSTEM

DISCUSSION

The discussions featured in this supplement to Retina Today are based on panel discussions held during the
2008 American Academy of Ophthalmology meeting in Atlanta.

David S. Boyer, MD, is a Clinical Professor of Stanislao Rizzo, MD, is at the Eye Surgery Clinic,
Ophthalmology at the University of Southern Santa Chiara Hospital, in Pisa, Italy. Dr. Rizzo is
California Keck School of Medicine, Department a member of the Retina Today Editorial Board.
of Ophthalmology in Los Angeles. Dr. Boyer is a
member of the Retina Today Editorial Board.
Pravin U. Dugel, MD, is Managing Partner of
Retinal Consultants of Arizona and Founding
Timothy G. Murray, MD, MBA, FACS, is Member of the Spectra Eye Institute in Sun
Professor of Ophthalmology and Radiation City, AZ. Dr. Dugel is a member of the Retina
Oncology at the Bascom Palmer Eye Institute, Today Editorial Board.
University of Miami Miller School of Medicine.
Peter K. Kaiser, MD, is in the Vitreoretinal
Department at the Cole Eye Institute,
Cleveland Clinic. Dr. Kaiser is a member of the
Retina Today Editorial Board.

David S. Boyer, MD: Key features of the CONSTELLATION Pravin U. Dugel, MD: Duty cycle is an important
Vision System (Alcon Laboratories, Inc., Fort Worth, TX) that parameter, albeit a newer concept to retina surgeons. By
distinguish this system from other technology for vitreoretinal definition, duty cycle is the percentage of time that the
surgical procedures include high-speed cut rate and duty cycle cutter is open compared to the overall cut cycle time.
control. How do these features translate to practice? Although there are specific percentages that can be
assigned to the duty cycle, we usually refer to three: closed
Stanislao Rizzo, MD: High cutting speed is important for bias, open bias, and 50/50. In closed bias, the cutter mouth
safety because it should translate to less traction on the retina. is closed most of the time and flow is reduced; in open
Duty cycle is important because it allows me a new variable bias, it is open and flow is increased. In 50/50, as one would
to control flow. assume, the amount of open-time and closed-time is equal
and flow is moderate.
Timothy G. Murray, MD, MBA, FACS: For higher- Duty cycle allows the surgeon to change flow without
volume vitreoretinal surgeons, the CONSTELLATION system changing cut rate or vacuum, which is a significant improve-
is revolutionary. For the first time in my experience, technolo- ment over the spring technology we have been using. As cut-
gy is not an impediment in surgery. I prefer to cut at high ting rates were increasing, the limits of the spring-loaded cut-
rates, taking small pieces of tissue and minimizing the transla- ter were maximized and the port was unable to stay open
tional forces on the peripheral tissue. The limitation with pre- long enough for such fast cut rates. For example, with the
vious technology is primarily the inability to maintain good ACCURUS (Alcon Laboratories, Inc.) at 2500 cpm, the port is
flow at high cut rates. In core vitrectomy, I will use an open- only open approximately 30% to 40% of the cutting time.
bias cutter operating at 5000 cpm, and I can now switch to a The new design of the ULTRAVIT cutter contains no springs,
closed duty cycle and shave tissue off the retinal surface with so there are two separate air lines, which means that duty
no movement to the detached or attached retina. So, for the cycle is completely in the control of the surgeon. One can cut
first time, we are able to maintain 5000 cpm with the ability at 5000 cpm and keep an open-bias duty cycle, eliminating
to have the flow characteristics for both core vitrectomy and the problem of decreasing flow.
those consistent with detached retina manipulation. Finally, duty cycle allows for excellent followability when
dealing with fibrous tissue or retained lens material.
Dr. Boyer: Dr. Dugel, can you explain duty cycle control
and its importance to complication prevention?
(Continued on page 10)

6 I SUPPLEMENT TO RETINA TODAY I MARCH 2009

 CLINICAL EXPERIENCE WITH THE CONSTELLATION VISION SYSTEM

Advances in Illumination
BY ROGER NOVACK, MD, P H D, FACS

I
n the past 5 years, there have been significant and regulates the initial light output based on gauge
advancements made to illumination for vitreo- and type of fiber optic.
retinal procedures. The illumination on the
ACCURUS system (Alcon Laboratories, Inc., XENON TECHNOLOGY
Fort Worth, TX) has improved from using a halogen The new xenon bulb on the CONSTELLATION system
bulb to xenon light source technology. In this article, provides bright, white xenon light to the maximum level
I will describe the illumination technology on the allowed under current FDA irradiance limits.
new CONSTELLATION Vision System (Alcon The halogen light on the original ACCURUS was fairly
Laboratories, Inc.). faint and yellowish, and provided limited visibility. The
xenon bulb on the ALCON AHBI (ACCURUS High-
SYSTEM IMPROVEMENTS Brightness Illuminator), provided improvement in
The CONSTELLATION system has four ports for brightness and was filtered toward blue. The chromati-
illumination, although the system allows the use of city diagram in Figure 1 shows the color spectrum of the
only two ports at any given time. A surgeon retains ACCURUS halogen light, the ACCURUS xenon, the
an advantage from the additional ports, because a CONSTELLATION xenon, and the MILLENNIUM (Bausch
combination of any two of these can be used simul- & Lomb, Rochester, NY) metal-halide light source.
taneously. The xenon light source on the CONSTELLATION has
The improvements to the illumination system on moved away from blue light, retaining the white light,
the CONSTELLATION include: brightness and color which has high-energy wavelengths that are easily
that enhance visualization and enables surgeons to absorbed by the retina.
have visibility in corners of the retina that were previ- The design of the illuminator (Figure 2) is different from
ously unable to be viewed; a longer bulb life than on other systems in that there is not a beam splitter, which can
the ACCURUS, which could decrease costs because degrade the quality and intensity of the light. Rather, the
the bulb needs to be changed less frequently; and the CONSTELLATION illuminator uses a whole mirror system
ENGAUGE Radio Frequency Identification (RFID) so that that same image is reflected to two separate path-
probe recognition, which makes setup much easier ways. The collimating lenses focus all light into the ports.

Figure 1. The color spectrum of the ACCURUS halogen Figure 2. The illuminator design on the CONSTELLATION
light, the ALCON AHBI xenon, the CONSTELLATION xenon, system.
and the MILLENNIUM metal-halide, the ACCURUS xenon.

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CLINICAL EXPERIENCE WITH THE CONSTELLATION VISION SYSTEM

BULB LIFE of a 20-gauge system, reducing light by approximately

The CONSTELLATION has been designed for more 70%. In 20-gauge surgery, the halogen output is
consistent light output over time. In the first 200 hours, 10 lumens, whereas with 25 gauge, the output is
the light output is extremely stable. The orientation of reduced to 3 lumens, which is inadequate for surgery.
the lamp produces highly uniform illumination and the Even with the use of illuminated instruments, it is diffi-
precise design and alignment of the fiber and bulb cap- cult to see at that power. The new SAPPHIRE Wide-
ture more light for better uniformity and efficiency. Angle Illuminator (Alcon Laboratories, Inc.) has a
The CONSTELLATION system indicates how many 750-µm fiber that goes from the machine all the way
hours of illumination have been used. The life of the into the handle of the light pipe. The viewing angle on
long-lasting xenon bulb is tracked by the system and pro- the SAPPHIRE is greater than 106º for 20-, 23-, 25-gauge
vides total lamp hour and colored indicator ring feed- surgery, and the light fiber can be used with any of the
back on lamp life: the green ring indicates from 0 to 200 Alcon light sources.
hours; the yellow ring indicates from 201 to 400 hours;
and the orange ring indicates from 401 to 800 hours. SUMMARY
The improved illumination on the CONSTELLATION
RFID SYSTEM Vision System, in terms of brightness, quality, stability, and
The ENGAUGE RFID system automatically recognizes ease of use has answered many of the difficulties of visual-
the type of Alcon device that is being connected, and pop- ization that surgeons have experienced with small-gauge
ulates the proper probe and gauge size into the system. surgery. The retina can now be viewed with more clarity,
The ENGAUGE RFID also provides a standard default set- and the improved angle of the light will now allow sur-
point feature that utilizes the probe and gauge informa- geons to see a wider area of the retina when operating. ■
tion and automatically puts the surgeon at the default.
For example, if the surgeon is using a straight or BULLET Roger Novack, MD, PhD, FACS, is a Partner
Wide-Angle Illuminator (Alcon Laboratories, Inc.), the sys- in the Retina Vitreous Associates Medical
tem will default to a consistent 8 to 10 lumens light out- Group, Los Angeles, California and Assistant
put. The surgeon maintains the ability to override the sys- Clinical Professor at the Jules Stein Eye
tem and increase illumination, if needed, to the maximum Institute Geffen School of Medicine,
US Food and Drug Adminstration-allowed output. University of California Los Angeles. Dr. Novack is a
paid consultant of Alcon Laboratories and Optos
FIBER OPTICS Corporation. Dr. Novack can be reached at +1 213 483
One of the challenges of 25-gauge surgery using halo- 8810; fax: +1 213 481 1503; or via e-mail:
gen illumination was that the fiber itself is half the size [email protected].

DISCUSSION

Dr. Boyer: Do you routinely use triamcinolone for Dr. Boyer: Dr. Murray, can you discuss illumination?
visualization?
Dr. Murray: The light source on the CONSTELLATION
Dr. Kaiser: I have used triamcinolone acetonide injectable Vision System has four ports available for illumination. The
suspension (TRIESENCE, Alcon Laboratories, Inc.). I use new RFID technology recognizes a light probe when plugged
TRIESENCE only for cases of posterior hyaloid traction with into the system, so that when you plug an instrument into
diabetes, where the vitreous is difficult to see. When I am the port, the system prepopulates the settings for the correct
working with fellows, I frequently inject Triesence—it is a light output. The ideal technology, in my opinion, is
great teaching tool because it enables clear visualization of advanced, but I also want simplicity in the delivery, both of
the vitreous. which the CONSTELLATION delivers.

Dr. Rizzo: There are some cases, such as when a surgeon Dr. Kaiser: Having multiple ports for lighting is a significant
must differentiate an eye with vitreous schisis from a case of advantage because you can add a chandelier or another light
posterior vitreous detachment, for which triamcinolone must source if needed, and the RFID ensures that the light output
be used. will be appropriate for 20-, 23-, or 25-gauge surgery.

8 I SUPPLEMENT TO RETINA TODAY I MARCH 2009

 CLINICAL EXPERIENCE WITH THE CONSTELLATION VISION SYSTEM

Integrated Infusion Pressure

and IOP Control
BY DAVID S. DYER, MD

W
hen performing vitrectomy, one of the want to maintain 32 mm Hg, I need more infusion com-
challenges that surgeons have faced is ing out of the system. The compensation calculation
controlling intraocular pressure (IOP) in that takes place at 20 cc/min with a 23-gauge cannula
relation to the pressure of the fluid that is and a pressure tubing and cannula drop of 22 mm Hg
infused through the cannula during surgery. uses the pressure set point plus the pressure drop to
Improvements in the CONSTELLATION Vision System determine the infusion pressure.
(Alcon Laboratories, Inc., Fort Worth, TX) include a new
integrated infusion pressure and IOP control system, AUTO INFUSION VALVE
which represents a significant advancement in safety for Another useful feature that has been included on the
vitrectomy. This article will describe the features on the CONSTELLATION fluidics system is the auto-infusion
CONSTELLATION system that work to control fluidics valve, which allows the surgeon to control an automated
during surgery. air:fluid exchange. The stopcock does not need to be
manually switched; the surgeon activates using the
IOP CONTROL footpedal or pushes a button on the display to initiate
IOP control is a significant advancement in vitrectomy air:fluid exchange, reducing errors or delays.
surgery. IOP control can assist with sudden bleeding in
patients with diabetes due to pressure changes, and BOTTLE MONITORING
makes it easier for the surgeon to control bleeding dur- New efficiency features on the CONSTELLATION sys-
ing surgery. Additionally, this feature has allowed me to tem include the ability to change the balanced salt solu-
set a lower IOP during surgery because the lag time in tion bottle during surgery with no need to stop, plug, and
adjustment is eliminated.
The ACCURUS Surgical System (Alcon
Laboratories, Inc.) utilizes gravity as fluidics control
with an automated IV pole or vented gas forced
infusion (VGFI) to control IOP. In VGFI, gas is driven
by pressurizing the bottle via low-pressure air pump.
The stopcock is controlled manually, and the IOP
must be offset artificially at 35 mm Hg to 45 mm Hg
to ensure globe stability during aspiration. Pressure
in static condition is consequently higher than need-
ed. Conversely, the pressure might be set at 32 mm
Hg for a static eye, but if there is a leak or aspiration
along the tubing, the pressure drops unexpectedly.
The IOP control on the CONSTELLATION sys-
tem automatically adjusts for the infusion tubing
and pressure drop that occurs when fluid is flowing
through the cannula by measuring and checking
the infusion cannula and tubing resistance during
priming. With the CONSTELLATION, the IOP is
maintained to within ±2 mm Hg of the surgeon’s
setpoint. Figure 1 shows the IOP compensation cal-
culation that is used for the CONSTELLATION. If I Figure 1. More infusion is required to maintain pressure.

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CLINICAL EXPERIENCE WITH THE CONSTELLATION VISION SYSTEM

clamp. Additionally, the CONSTELLATION calculates fluid and the automated features on the system save time and
use, estimates how much fluid is in the bottle, and issues a reduce errors that are inherent in manual procedures. ■
warning when the fluid is low.
David S. Dyer, MD, is in private practice in
SUMMARY Shawnee Mission, KS. Dr. Dyer states that he is
The CONSTELLATION fluidics represent a significant a member of the Retina Advisory Council for
advancement over previous technology. The more accurate Alcon Laboratories, Inc. He can be reached by
and responsive IOP management enhances surgeon control e-mail at [email protected].

DISCUSSION

Dr. Boyer: The intraocular pressure (IOP) control with the with a nuclear fragment, breakage can cause a massive
CONSTELLATION system is phenomenal. In the past, we sudden surge of fluid out of the eye and subsequent
routinely experienced hypotony as the scleral depression was hypotony. For older patients, there can be a high risk of
relaxed; however, the fluidics on the CONSTELLATION sys- choroidal hemorrhage, but this is not an issue with the
tem help maintain IOP within approximately 2 mm Hg. With CONSTELLATION system and its excellent IOP control.
previous technology, I typically perform vitreoretinal proce- The system constantly monitors the IOP so that if an
dures beginning with an IOP of approximately 40 mm Hg to occlusion break occurs, the fluidics automatically adjusts
allow for fluctuation and to lower the risk of hypotony. With to protect against hypotony.
the CONSTELLATION, I set the IOP at 20 mm Hg.
Dr. Rizzo: The IOP control system on the CONSTELLATION
Dr. Kaiser: Another factor that has a role in IOP con- works quickly. I found that drops in pressure lasted merely mil-
trol is fragmatome placement. When there is an occlusion liseconds before the IOP returned to the original level. ■

DISCUSSION

(Continued from page 6) The cutter on the CONSTELLATION is specifically designed

Dr. Boyer: When converting from 20-gauge vitrectomy to for small-gauge surgery, as opposed to previous technology
23- or 25-gauge surgery, are there cases you would avoid? that basically took large-gauge instrumentation and shrunk it
down to fit, using the same basis for fluidics.
Dr. Rizzo: I might avoid cases of macular pucker because On the CONSTELLATION, the cutter is not just a cutter
the vitreous can be unpredictable. anymore. Port optimization, which moves the port closer
to the tip of the probe enables me to have better flow con-
Dr. Dugel: I have performed 23-gauge surgery for 2 years, trol with duty cycle, but also makes the cutter a multifunc-
and would not avoid any cases with this technology. In fact, I tional tool, reducing my need for horizontal and vertical
would propose that it is the hardest cases in where the fea- scissors.
tures on the CONSTELLATION become most useful. For
example, a combined traction and rhegmatogenous retinal Peter K. Kaiser, MD: The CONSTELLATION Vision
detachment can begin with a core-mode setting at 4000 cpm System also offers the ability to micropulse and proportion-
to 5000 cpm, and open-bias duty cycle, and vacuum of ately control reflux. The cassette on the CONSTELLATION
400 mm Hg to 500 mm Hg. The detached retina can then be allows an increase of fluid that is proportional to the circum-
addressed in shave mode, keeping the cut speed at 5000 cpm, stances. For example, if you are operating on a patient with
with an open duty cycle to reduce the flow. After shave mode diabetes who begins to bleed, you can switch to proportional
is complete, the cut rate can be decreased to 3000 cpm, and reflux mode and the fluid will increase to the extent where it
the duty cycle can be adjusted to open-bias, allowing the sur- effectively pushes the blood out of the way. ■
geon to address the fibrous tissue.

10 I SUPPLEMENT TO RETINA TODAY I MARCH 2009

 CLINICAL EXPERIENCE WITH THE CONSTELLATION VISION SYSTEM

Clinical Experience
With the PUREPOINT Laser
BY TIMOTHY G. MURRAY, MD, MBA, FACS

T
he embedded PUREPOINT 532 nm photoco-
agulator on the CONSTELLATION Vision
System (Alcon Laboratories, Inc., Fort Worth,
TX; Figure 1) is both complex in design and
function yet extremely simple to use. The features on
the laser increase overall surgeon control and precision
and help to streamline surgical procedures for better
efficiency and safety.
In my opinion, there are three critical benefits to
PUREPOINT laser: increased surgeon control, decreased
reliance on surgical staff, and enhanced delivery of quality
care. In this article, I describe the key features on the
PUREPOINT and how each improves my surgical
procedure. Figure 1. The embedded PUREPOINT laser.

“This next generation of Alcon laser

probes represent intelligent design
and a significant step forward in
vitreoretinal surgery. ”

SYSTEM FEATURES
ENGAUGE Radio Frequency Identification (RFID) Figure 2. The Flexible Tip Laser Probe (FLP).
allows the laser to automatically recognize the device that
is being plugged in and immediately populate the param- as insertion accuracy tools for the person who is plug-
eters accordingly. ging in the laser delivery devices.
With the footpedal on the PUREPOINT laser, the sur-
geon can switch the laser from standby to ready and THE ENDOLASER PROBE
power delivery can be altered up and down on the laser. The endolaser probe that I use with the PUREPOINT
Additionally, voice confirmation occurs when parame- laser system is the curved Flexible Tip Laser Probe
ters are changed. (FLP; Figure 2). The FLP has a 33-gauge nitinol tip
There are two ports on the PUREPOINT laser, which with a 40º-bend angle and a 6-mm bend radius. The
enable the endolaser and the laser indirect ophthalmo- overall length of the probe is approximately 26 mm
scope (LIO) to be simultaneously plugged in. The and the construction is a rigid, thick-walled, tapered
switch from endolaser to LIO, and vice versa, can be cannula.
performed on the same platform without any alter- The nitinol tip on the FLP can be straightened to go
ations required from staff. through the trocar and reassumes its curvature once
The ports also have color ring indicator lights that act the probe has entered the eye. The small-tip diameter

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CLINICAL EXPERIENCE WITH THE CONSTELLATION VISION SYSTEM

Figure 3. With a compact tip radius and shorter overall tip length, the FLP provides broad access to the peripheral retina.

and tapered cannula allows for easier insertion into the of Alcon laser probes represent intelligent design and a
trocar and, once in the eye, the flexible curved tip significant step forward in vitreoretinal surgery.
allows for greater access to the periphery (Figure 3). The
configuration of the FLP minimizes retina touch and PLATFORM STABILITY
contact with the crystalline lens, reducing the risk of I have been most impressed with the stability of
secondary cataract. Alcon’s laser platform throughout the evolution of the
The laser probe that I used previously was the Stepped technology. The stability of the new-generation
Angle Probe (Iridex Corporation, Mountain View, CA). PUREPOINT photocoagulator is further improved to
The Stepped Angle Probe has a larger entry diameter and significantly increase the quality of the laser burn that
a fixed angle that is not continuously curved. The angula- it delivers. The PUREPOINT laser has a high-energy
tion of this probe increases the likelihood that it will have capacity, multiple mode settings, and micropulse and
contact with the lens. I have also used a directional laser continuous laser modes. In summary, the PUREPOINT
probe which has a separate fiber that extends from the laser delivers reproducible, targeted, and precise laser
end. Although this is a more difficult probe to use, it energy. ■
remains an excellent tool when used correctly.
My idea of superior surgical instrument design, how- Timothy G. Murray, MD, MBA, FACS, is
ever, is that which takes into account all users. In my Professor of Ophthalmology and Radiation
opinion, the best design results in instrumentation that, Oncology at the Bascom Palmer Eye Institute,
if put into the hands of a retina fellow, would enhance University of Miami Miller School of Medicine. Dr.
his or her ability to achieve the surgical goal and Murray is a consultant for Alcon Laboratories,
increase the overall safety profile. This next generation Inc. He can be reached at [email protected].

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 CLINICAL EXPERIENCE WITH THE CONSTELLATION VISION SYSTEM

Surgical Efficiencies on the

CONSTELLATION Vision System
BY PRAVIN U. DUGEL, MD

W
ebster’s Dictionary defines efficiency as
“the safe production of the desired “The bar-code scanner enables
effects or results with minimum waste of technicians to scan the disposable
time, effort or skill.” Safety is the primary
component in the surgical efficiencies that are delivered vitrectomy pak and the system will
by the V-LOCITY Efficiency Components on the automatically recognize whether it is
CONSTELLATION Vision System (Alcon Laboratories,
Inc., Fort Worth, TX). This article will review the 20, 23, or 25 gauge. ”
V-LOCITY Efficiency Components, focusing on how
each feature increases the safe delivery of care to our CONSTELLATION system, can be used as either a pri-
patients. mary resource or as a refresher.
Additional smart components on the
PREOPERATIVE COMPONENTS CONSTELLATION system are ENGAUGE Radio
A common concern among vitreoretinal surgeons is Frequency Identification (RFID) and a bar-code scan-
the shortage of experienced and educated surgical staff. ner which works to simplify setup of the system. The
To that end, the V-LOCITY system incorporates two dif- bar-code scanner enables technicians to scan the dis-
ferent avenues for staff education: V-LOCITY Help and posable vitrectomy pak and the system will automati-
Wizard Help. V-LOCITY Help allows for a detailed cally recognize whether it is 20, 23, or 25 gauge. The
review of procedures, with step-by-step instruction and ring lighting system indicates whether the probes have
surgical videos. Wizard Help goes even further by allow- been plugged in correctly (initially blue, the light will
ing stop and start setup, which provides similar instruc- change to green with proper insertion or amber for
tion and videos, but that can be paused so that techni- improper insertion). Additionally the RFID system will
cians can perform the actions described and then con- automatically normalize the light output for the tech-
tinue the video instruction as they move along in the nology being used.
process. These features, embedded into the The other function of the bar code scanner is to

Figure 1. Push priming on the CONSTELLATION system Figure 2. The auto-infusion valve allows the surgeon to easily
allows for fast priming, IOP control, and one-button priming. switch to air without assistance from surgical staff.

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CLINICAL EXPERIENCE WITH THE CONSTELLATION VISION SYSTEM

Figure 3. The auto gas fill mechanism is practical in terms of Figure 4. End-case metrics provide a summary of the proce-
accuracy and cost savings. dure, including surgical times and materials consumed.

monitor and record the vitrectomy packs or consum- Although I prefer not to use diathermy in my proce-
ables that are being used at any time during a proce- dures, Alcon has improved on this technology with
dure with automatic population of the consumables list proportional diathermy, which allows full surgeon con-
window, which is a useful function for inventory control trol. The surgeon can increase the diathermy to con-
and billing. trol bleeding. The higher frequency in proportional
Push priming on the CONSTELLATION system allows diathermy translates to a more confined treatment
for fast priming for 20-, 23-, and 25-gauge vitrectomy. that has a lower amount of penetration.
The system is automatically calibrated for intraocular The reflux options allow for microreflux, which is
pressure (IOP) control and allows one-button priming short duration of pressure that is provided to the suc-
of all surgical functions. This feature is critical in tion port to blow away the blood from the top of the
improving efficiency of OR turnover. As seen in Figure 1, retina, and to which most surgeons are accustomed.
a green bar runs along each station, and if there is a Proportional reflux, however, is an entirely new innova-
problem at any point, the bar becomes amber and tion that provides power to the suction port that works
stops the machine, so the scrub tech can locate the more like a windshield wiper—it enables the surgeon to
problem and correct it immediately. gradually and slowly wipe the blood away in a con-
Another feature of the V-LOCITY Efficiency trolled manner, using pressure from 0 mm Hg to
Components that I find to be important is the articulat- 120 mm Hg.
ing arm. The arm is completely maneuverable, flexible, The V-LOCITY autogas fill component (Figure 3)
draped for sterility, and can be easily adjusted with one allows the scrub tech to completely fill the syringe with
hand. pure intraocular gas, either C3F8 or SF6. This component
These preoperative components allow surgery to be both improves efficiency and reduces waste of a signifi-
set up by one individual, and the surgeon merely sits cantly expensive surgical tool.
down and starts operating.
POSTOPERATIVE COMPONENTS
OPERATIVE COMPONENTS At the end of surgery, the V-LOCITY Efficiency
During surgery, there are several components that Components produces end-case metrics (Figure 4),
improve efficiency. The first is the auto-infusion valve which summarize the procedure, how much vitrecto-
(Figure 2). The auto infusion valve allows the surgeon my and phaco time was used, the power used, among
to switch from fluid to air with a simple toggle of the other factors. An equally powerful postoperative tool
switch on the foot pedal, eliminating the need for a is the operative record (Figure 4), which generates a
scrub tech or the circulator to be involved. The list of all the consumables used during a procedure
embedded PUREPOINT laser (Alcon Laboratories, Inc.) and that can be transmitted to a wireless printer. In
with voice recognition and multifunction foot pedal, is one report, inventory control, billing, and dictation are
also a vast improvement over older systems. simplified.

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 CLINICAL EXPERIENCE WITH THE CONSTELLATION VISION SYSTEM

CASE REPORTS myself, and then used the PurePoint laser and finished
To illustrate how the V-LOCITY Efficiency with a gas fill. What is critical about the V-LOCITY
Components fit into surgery, I will describe one of the Efficiency Components in this case, is that, except for the
first cases that I performed with the CONSTELLATION gas fill, all steps in the procedure can be completed by the
Vision System. A young, poorly compliant patient with surgeon. We have never before had a machine that con-
diabetes presented with a combined traction and rheg- centrates solely on the surgeon and with the
matogenous retinal detachment. For this patient, I per- CONSTELLATION, all that is required for a safe and effi-
formed a core vitrectomy with a speed of 4000 cpm, cient procedure is the surgeon and a good scrub tech.
vacuum of 400 mm Hg, and an open-bias duty cycle to
allow high flow. When I went close to the retina, I WHERE EFFICIENCY MATTERS
switched to shave mode at 5000 cpm, vacuum of Whether you are operating in an ambulatory surgery
400 mm Hg, and a closed-bias duty cycle to limit flow. center setting or a hospital setting, the V-LOCITY
Upon encountering thick adherent tissue in the Efficiency Components on the CONSTELLATION system
detached retina with all the vitreous removed, I was increase safety and efficiency, allowing vitreoretinal sur-
comfortable decreasing my cut rate to 3000 cpm, and geons more control than has ever been available. This
keeping vacuum constant with an open-bias duty cycle machine has fewer steps to get the job done than ever. ■
for increased followability. An open-bias duty cycle is
useful not only for fibrous tissue, but also for retained Pravin U. Dugel, MD, is Managing Partner of
lens material. Retinal Consultants of Arizona and Founding
I set my IOP control higher, at about 40 mm Hg, and Member of the Spectra Eye Institute in Sun
although I did not have to use diathermy for this case, City, AZ. He is a Retina Today Editorial Board
the proportional component was there if I had needed it. Member. Dr. Dugel can be reached via e-mail
I initiated fluid-air exchange with the pedal, toggling it at [email protected].

“The V-LOCITY Efficiency

Components on the
CONSTELLATION system
increase safety and
efficiency, allowing
vitreoretinal surgeons
more control than has
ever been available.”

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CON131