I was in my residency in 1970 when the pioneering work on mechanical vitrectomy was done by Robert Machemer, MD. It was quickly learned that piston-like guillotine cutters were safer with less traction on the retina than rotary cutters. I started with the Ocutome, which required a separate machine as the phacoemulsification machines of that day did not have vitrectors incorporated into them. Fortunately, today all phacoemulsification equipment comes with an integrated vitrector.
In the ensuing 45 years, guillotine cutters have dominated the field. Over the decades, they have become smaller, advancing from 17 gauge to options as small as 27 gauge today. Cutting rates have increased dramatically, and the size of the port opening has decreased. Advances in fluidics, light sources, visualization and ancillary instruments have proliferated. All of these incremental advances have made the surgery safer and more effective. But 45 years later, just like ultrasound retains primacy in phacoemulsification, which evolved over the same time period, guillotine cutters dominate vitrectomy, whether performed by the vitreoretinal or anterior segment surgeon.
The recent FDA clearance and CE mark of the Bausch + Lomb Vitesse hypersonic vitrectomy system now offer anterior and posterior segment surgeons a legitimate alternative for their vitrectomies. I was first introduced to the Vitesse hypersonic vitrectomy system while consulting for Bausch + Lomb about 5 years ago. It was fascinating in the laboratory to watch vitreous seemingly liquefy and disappear in animal and cadaver human eyes with minimal traction and turbulence.
There is much yet to learn about this new approach to vitrectomy, but early adopters, as noted in the accompanying cover story, are positive. I think anterior segment surgeons will find this device very attractive for vitreous removal during anterior segment reconstruction, penetrating keratoplasty and cataract surgery. It is still uncertain whether hypersonic vitrectomy can cut the dense vitreous strands often encountered by the vitreoretinal surgeon, but for the typical anterior vitrectomy required for the cataract, corneal and glaucoma surgeon, the technology looks very promising. The probe size is currently 17 gauge, which will require a larger incision, but I am looking forward to evaluating hypersonic vitrectomy on our recently acquired Stellaris Elite phacoemulsification machines in the near future.
It is exciting to see new, potentially disruptive technology continuing to be developed in ophthalmology. After nearly 50 years, cataract removal is slowly reducing its dependence on ultrasound and evolving toward phacoaspiration as lenses become softer and fluidics advance. It will be interesting to see if hypersonic vitrectomy begins to replace the guillotine cutters of the last 5 decades at the same time.
Disclosure: Lindstrom reports he is a consultant for Bausch + Lomb, Johnson & Johnson Vision and Alcon.