PPV was performed by 2 experienced retinal specialists (SJW and KHP). A 23/25-gauge transconjunctival sutureless vitrectomy was performed using an Accurus 800CS surgical system (Alcon, Fort Worth, TX, USA) or Constellation system (Alcon) with contact lens (Hoya, Tokyo, Japan). Phacoemulsification with intraocular lens implantation was performed before vitrectomy in patients with significant cataract. The peeling of the ILM was performed using end-gripping forceps (Alcon). Triamcinolone acetonide (1%; Hanmi Pharmaceutical, Seoul, Korea) or 0.05% indocyanine green (Dong In Dang Pharmaceutical, Siheung, Korea) were used for staining and peeling of ILM. Foveal sparing ILM peeling was performed in 7 eyes and complete ILM peeling up to the temporal arcade was performed in the remaining 33 eyes. Gas tamponade with 14% perfluoropropane or 18% sulfur hexafluoride was done in 19 eyes. Prednisolone acetate (1%; Pred Forte, Allergan, Irvine, CA, USA) and 0.5% levofloxacin (Cravit; Santen Pharmaceutical, Osaka, Japan), were topically instilled 4 times a day for 4 weeks.
Constellation system
Manufactured by Alcon
Sourced in United States
The Constellation system is a versatile and advanced surgical console designed for ophthalmic procedures. It features a modular design that allows for the integration of various surgical devices and instruments, enabling surgeons to perform a wide range of procedures with precision and efficiency.
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15 protocols using constellation system
1
Transconjunctival Sutureless Vitrectomy for Retinal Disorders
2
Surgical Procedure for Retinal Break Repair
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M.S. performed all surgical procedures with the Alcon Constellation system (Alcon Laboratories, Inc, Fort Worth, TX) as follows: A retrobulbar block was performed followed by placement of three 23-gauge trocars. A complete vitrectomy including a meticulous peripheral vitreous shave was performed. Retina was repositioned with either liquid perfluorocarbon or air ensuring that the borders of the lesions were completely attached and no subretinal fluid was left. Laser photocoagulation was applied around the retinal breaks. Perflurocarbon–liquid–air exchange was performed. Once the eye was full of air, tailored pieces of lyophilized HAM between 3 to 6 mm in diameter (Fig. 1 ) were introduced using a 25-gauge forceps through a 23-gauge valved trocar (mismatched caliber was intentional for better tissue handling) and deployed over the retinal breaks. As a result of this procedure, a LAMPatch was firmly placed against the retina, covering the break. (Fig. 2 ) Neither gas nor silicon oil were injected. The trocars were then removed, and the sclerotomies were sutured if needed. Subconjunctival injection of cefazolin was administered.![]()
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LAMPatch trimming under optical microscope before been introduced inside the eye
LAMPatch (Black arrow) adhered to the retinal surface covering the retinal break
3
PPV and HA-engineered Hydrogel Treatment
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The conjunctiva was prepared using a 5% povidone-iodine solution. Using three ports 1 mm from the corneoscleral limbus, 25-gauge PPV was performed in all study rabbits using a Constellation system (Alcon Laboratories, Inc., Fort Worth, TX, United States) by an experienced vitreoretinal surgeon (X.R.); one port was used for the infusion cannula, while the other two ports were used for the vitreous cutter and endoilluminator optical fiber. Sclerotomy was performed via biplanar entry using a trocar and cannula, initially tangential to the sclera and then perpendicular, to create a self-sealing incision. The lens was not removed. Core vitrectomy was performed under a surgical microscope with a fundus wide-angle viewing system (Volk Mini Quad XL; Volk Optical, Inc., Mentor, OH, United States), and posterior vitreous detachment (PVD) was created using triamcinolone acetonide. Fluid–air exchange was performed, and 0.1 ml HA-engineered hydrogel was applied with a 27-gauge needle through a trocar and cannula to cover the retina at 2 disc diameters (DD) below the optic disc. The microcannulas were removed after vitrectomy, and the sclerotized area was gently massaged with a cotton-tipped applicator to prevent leakage. The surgical eyes received eye drops containing antibiotics and dexamethasone for 1 week after surgery.
4
Retinal Tear Repair with PPV and Laser
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All procedures were executed under regional anesthesia using an injection of 2 mL of 0.5% bupivacaine and 2 mL of 2% lidocaine. A regular three-port 25-gauge PPV was performed using the Alcon Constellation system, along with a non-contact wide viewing lens (LPU CLA 200). Triamcinolone acetonide was used to assist in the removal of both central and peripheral vitreous. A 360° scleral indentation was performed to shave the vitreous base and release vitreous traction around the retinal tear. Subsequently, a fluid-air exchange was initiated at a pressure of 45 mmHg, and subretinal fluid was drained using a flute needle through the primary retinal break. Endolaser was then used to create 3-4 rows of laser photocoagulation around the retinal break. Finally, the intraocular pressure was set to 35 mmHg for inferior breaks and 30 mmHg for superior breaks. The three-port scleral incisions were closed with 8-0 absorbable sutures. Patients were nursed in a face-down or lateral position to ensure that the air tamponade fully compressed the retinal breaks.
5
Surgical Techniques for Rhegmatogenous Retinal Detachment
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Surgery was undertaken by one of the authors with a standard 25-gauge vitrectomy using the Alcon Constellation System. No case had cataract surgery/lensectomy at the time of the primary RD repair. Laser was the only type of retinopexy used in these cases. It was at the surgeon’s discretion as to whether a scleral buckle was to be used adjunctively, 360-degree laser retinopexy or limited laser retinopexy was used and the type of tamponade. If silicone oil was used 5700 centistoke oil was used exclusively.
The indication for 360-degree laser was again at the surgeon’s discretion but included prophylaxis against missed or new breaks, extensive breaks or detachment, and in giant retinal tear related RRD. In general 360-degree laser retinopexy was to a light grey burn and was applied in a milder fashion compared to laser limited to around retinal breaks or a retinotomy.
The indication for 360-degree laser was again at the surgeon’s discretion but included prophylaxis against missed or new breaks, extensive breaks or detachment, and in giant retinal tear related RRD. In general 360-degree laser retinopexy was to a light grey burn and was applied in a milder fashion compared to laser limited to around retinal breaks or a retinotomy.
6
Primary RD Treatment by 23G Vitrectomy
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This is a consecutive, single-center case series of six eyes of six patients with primary RD treated by a single surgeon with pars plana 23-gauge vitrectomy with the Constellation System (Alcon Laboratories, Inc., Fort Worth, TX, USA). Inclusion criteria were: eyes with primary RD, single retinal breaks of less than one hour extension and minimal to no signs of vitreoretinal proliferation. Patients with previous retinal surgeries were excluded. Three cases had superior breaks, and three cases had inferior breaks. Surgical repair took place between November 2019 and June 2020. Written informed consent for participation was obtained from all patients. The study was in compliance with the Declaration of Helsinki. An independent ethical committee approved this study in accordance with the Helsinki declaration.
Preoperatively, an ophthalmic history and a complete ophthalmic examination including refraction with assessment of best-corrected visual acuity (BCVA) Goldmann applanation tonometry and a fundus dilated ophthalmic examination was performed.
Preoperatively, an ophthalmic history and a complete ophthalmic examination including refraction with assessment of best-corrected visual acuity (BCVA) Goldmann applanation tonometry and a fundus dilated ophthalmic examination was performed.
7
Finite Element Analysis of Phacoemulsification Fragmatomes
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Finite element calculations using the COMSOL Multiphysics system v3.5 (Palo Alto, CA) were used to elucidate the influence of wall thickness, tube length, and excitation frequency on a titanium alloy fragmatome tube with outer diameters of 20, 23, 25, and 27 gauge. By coupling a linear elastic model of structural mechanics, fluid mechanics, and acoustical physics, we were able to determine the eigenfrequencies as well as parameters in which the internal von Mises stress (force/area) in the fragmatome exceeds the yield strength and, thus, according to the von Mises yield criterion,16 the fragmatome can break apart. The finite element calculations allowed for visualization of the von Mises stress and volumetric strain (change in volume/volume) of the fragmatome. The fragmatomes simulated were made of titanium.
Typical driving frequencies for phacoemulsification systems and fragmatomes vary from 35 to 55 kHz and, for some of our calculations, we chose a “typical” ultrasonic frequency of 45 kHz. For comparison with the calculations included in this study, the fragmatome used with Alcon's Constellation system operates at a frequency of 39.0 ± 1.9 kHz and has a length of 30.5 mm. Relevant engineering terms used in this study, with their definition, can be found inAppendix Table A1 .
Typical driving frequencies for phacoemulsification systems and fragmatomes vary from 35 to 55 kHz and, for some of our calculations, we chose a “typical” ultrasonic frequency of 45 kHz. For comparison with the calculations included in this study, the fragmatome used with Alcon's Constellation system operates at a frequency of 39.0 ± 1.9 kHz and has a length of 30.5 mm. Relevant engineering terms used in this study, with their definition, can be found in
8
Standard 3-Port Pars Plana Vitrectomy Procedure
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Standard 3-port pars plana vitrectomy was performed with 25-gauge instruments as described in detail previously. [18 (link)] None of the patients had concurrent scleral buckling surgery. Cataract surgery was performed through a 2.4-mm self-sealing superior sclerocorneal tunnel. A continuous curvilinear capsulorhexis was performed, and the lens nucleus was removed, and the residual cortex was aspirated with an irrigation/aspiration tip. Next, a foldable acrylic intraocular lens was implanted into the bag. A trocar was then inserted at approximately 30° parallel to the limbus with the bevel-side up. After creating 3 ports, vitrectomy was performed using the Constellation® system (Alcon Laboratories, Inc., Fort Worth, TX). After fluid-air exchange and subretinal fluid drainage from the causative retinal tear(s) or an iatrogenic hole, the causative retinal tear(s) or iatrogenic hole was photocoagulated. At the completion, 20% sulfur hexafluoride (SF6) was injected into the vitreous cavity. After the IOP was adjusted to a normal tension, the cannulae were withdrawn, and the sclera was pressed and massaged with an indenter to close the wound.
9
Standard 25G Pars Plana Vitrectomy
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A standard 25-gauge (G) three-port pars plana vitrectomy (PPV) was performed by one surgeon (TI) using the Constellation system (Alcon Laboratories, Inc., Fort Worth, TX, USA). After core vitrectomy, the ERM and ILM were peeled circumferentially from the retina with ILM-peeling forceps in all cases. Finally, we performed a peripheral vitrectomy with shaving and carefully inspection of the periphery over 360 degrees.
Cataract surgery and implanted a foldable acrylic IOL into the capsular bag were performed on all 19 phakic eyes.
Cataract surgery and implanted a foldable acrylic IOL into the capsular bag were performed on all 19 phakic eyes.
10
Pars Plana Vitrectomy Techniques and Outcomes
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All vitreoretinal surgeries were performed by the same experienced surgeon (D.S.C.) at a tertiary centre. The 23-gauge pars plana vitrectomies were performed under local anaesthesia, using the Constellation system (Alcon, Fort Worth, TX, USA). After three EdgePlus ® (Alcon, Fort Worth, TX, USA) valved cannulas were inserted, core and peripheral vitrectomy was performed. Detachment of the posterior hyaloid was performed if it was not present. During PPV, an ophthalmic balanced salt solution (BSS Plus, Alcon Laboratories, Fort Worth, TX, USA) was used as the intraocular irrigating solution. Should epiretinal membrane (ERM) or internal limiting membrane (ILM) peeling have been necessary, it was performed with the assistance of MEMBRANEBLUE-DUAL ® dye (D.O.R.C., The Netherlands). Laser photocoagulation and/or cryo-coagulation was performed as required. Three types of vitreous substitutes were used: no tamponade, gas (Perfluoropropane (C3F8) 12 %) or SO (RS OIL 1000 centistokes, AL.CHI.MI.A. SRL, Italy).
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