http://www.tvrs.gr/

1. Thomas M. Aaberg, Jr. M.D.
Retina Specialists of Michigan
Michigan State University
Grand Rapids, Michigan, U.S.A.
OFFICE PROCEDURE ROOM BASED
3 PORT VITRECTOMY SURGERY:
PROOF OF PRINCIPLE

2. FINANCIAL DISCLOSURES
Synergetics
Allergan

7. AS VITREORETINAL SURGEONS
HOW DO WE AVOID FORFEITING CONTROL?

8. SYSTEMS RELEVANT TO THE OPERATING ROOM

9. SYSTEM COMPONENTS
Facility Equipment Surgeon

10. • Expense
• Personnel
• Salary
• Benefits
• Anesthesia Equipment costs
• Property costs
• Rent
• Overhead
• Maintenance costs
• Influencing factors
• Efficiency
• Regional Cost of Living
• Regional Property values
• Income
• “Facility Fee”
• Set by Payers
FACILITY: EXPENSE AND INCOME

11. • Expense
• Cost versus quality
• Durable Capital Costs
• Surgical instrumentation
• Anesthesia equipment
• Furniture
• Information technology
• Disposable costs
• Instruments
• Surgical Packs
• Anesthesia Packs
• Medications
• Income
• Hospitals
• Limited pass through
reimbursement on disposable
instrumentation, medications,
etc.
• ASC
• None
EQUIPMENT ECONOMICS

12. • Expense And Income Dictated by:
• Efficiency
• Productivity
• Case Type
• Payer Contract
SURGEON ECONOMICS

13. HOW DO WE MODIFY THESE FACTORS
TO BENEFIT THE PATIENTS, THE PAYERS,
AND THE SURGEON?

14. ECONOMICS 101
• Increase Income
• Decrease Expenses

15. • Most challenging side of the economic
equation.
• Largely at the mercy of the Payer
contracts
• Increase efficiency
• Increase scope of practice
• Ability to manage previously
“unmanageable” (ex: macular
holes, or exudative AMD)
• Capture part or all of the global fee
(professional fee and facility fee)
INCREASE INCOME

16. • Eliminate overhead costs
• Personnel
• Equipment
• Facility
DECREASE EXPENSES

17. THE GREATEST
(AND SOMETIMES THE WORST IDEAS)
BEGIN WITH A FRIEND AND A BEER

18. Club Vit 2010
Sorrento

19. PEARL (VERSAVIT PROTOTYPE)
Variable Cut Rate
Variable Aspiration Pressure
50 cc Cassette
Variable Air Infusion
Pressure
Single Variable LED
Light Source

20. PERSONAL EXPERIENCE (PROTOTYPE)
• 7 cases
• ASC = 6
• Office = 1
• Procedures
• Macular Pucker (4)
• Macular Hole (1)
• Vitreomacular traction (1)
• Non-clearing vitreous hemorrhage with retinal tear (1)

21. PROTOTYPE PERSONAL EXPERIENCE
• Efficient
• Quiet
• Good illumination
• Extremely user friendly…”plug and play”

22. PROTOTYPE PERSONAL EXPERIENCE
• Prototype Glitches
• Foot pedal failure due to broken connection (cases 1, 2)
• Temporary loss of cutting ability (case 5)
• Surgical Complications
• None

23. PROTOTYPE PERSONAL EXPERIENCE
• Limitations
• No silicone oil infusion
• No fragmatome
• No diathermy

24. PERSONAL EXPERIENCE
• Surgical maneuvers performed
• Complete vitrectomy
• Injection and removal of vital dye
• Membrane peeling
• Fluid-air exchange
• Indirect laser retinopexy
• Endolaser retinopexy*
* Endolaser performed with separate unit (Iridex)

25. CASE EXAMPLE: CASE 5 (OFFICE)

26. OUTCOMES
• Vision: 7/7 > 2 lines of vision
• Preop Visual Acuity: 20/102 (range = 20/40 – 20/800)
• Postop Visual Acuity: 20/48 (range = 20/20 – 20/400)
• Anatomic success: 7/7 cases
• Surgical time: 38 minutes, mean (range = 24 – 52 minutes)
• Follow-up Period: 4 months, mean (range = 3 – 6 months)

27. PROTOTYPE DESIGN CHANGES
• Switches/Knobs
• Eliminate the rheostats and exchange them for switches
• Illumination
• Add a second light port for multiple illumination sources or in case of light source failure.
• Vacuum Pressure
• Increased and adjustable
• Foot Pedal
• More functional foot switch

28. PROTOTYPE DESIGN CHANGES
• Create a platform for expansion
• In time, surgeons will push the limits as to which cases they will conquer.
• The machine will not be the limiting factor.
• Accessories will be the “App” equivalents

29. VERSA VIT
SPECS
• Weighs 25 pounds
• Footprint less that
one cubic foot of
space

30. COMPACT PORTABLE VITRECTOMY UNIT
(SYNERGECTICS)
Variable cut rate
from 0-6000 cpm
Variable aspiration
from 0-500 mmHg
IOP control
from 0-120 mmHg
Current version has cutter bias open, neutral, or closed option

31. Cassette has 2 independently functioning 50 cc volume vials
Green and Red back lighting indicates volume status of the vial.

32. 2 Adjustable LED light sources
Rated for 25,000 hours = 3 years of continuous use.

33. VERSAVIT ILLUMINATION: FILTERED AT 435 NM

34. Output Spectral Power

35. 23G, 25G, OR 27G VITRECTOR POWERED BY
COMPRESSED GAS: CO2, NITROGEN, AIR
When using the CO2 cartridge, the unit provides 20 minutes of continuous cutting
with a cut rate of 1250 cpm. Requires shorter tubing set.

36. UNIT POWER: EXTERNAL POWER SUPPLY OR
BATTERY
The unit can run on battery power for up to one hour.

37. • Linear control of aspiration, from 0
to console setting
• Cutter on / off switch
• Rapid pressure adjustment switch
• Fixed cut rate set on the console
• Two other buttons for optional
equipment
• Example: diathermy
FOOT PEDAL

38. Core Essentials Packs
Efficiency Pack Configuration
• 20, 23, 25, and 27ga
• 6502XE – 6 foot cutter design
• 6503XE – 3 foot cutter design
Tyvek Lid Design
• Branding Core Essentials
• Stackability on shelf in office
• Label on the side

39. Port Entry Systems
 Synergetics Express™ 3-in-1 Port Entry System
• Available in One-Step blade at launch
• Coming soon with MID Labs blade
• Cost advantages
• No instrument transfer
• Scleral marker on back
• Cosmetic change
*Confidential*

40. Biopsy Kit
 Separate pack for biopsy
• In-line collection basin on cutter
• One Cannula Set
• No tubing
• Minimizing cost and setup
• Biopsy BT pack?
*Confidential*

41. Kirwin Bipolar Unit Synergetics Photon
Stand-alone Enhancements
Silicone Oil Injection
*Confidential*

43. VITRECTOMY UNIT COMPARISON
VersaVit Innovit Stellaris Constellation
Gauge 23,25,27 23 20,23,25 20,23,25,27
Cut Rate Max 2500 1200 5000 5000
Illumination LED None Xenon/Hg Xenon
Surgeon Control Foot Pedal Finger Foot Pedal Foot Pedal
IOP control X Gravity X X
Vacuum (max) 500 mmHg Manual 650 mmHg 650 mmHg
Viscous Fluid X 0 X X
Diathermy X 0 X X
Portable X X 0 0
Phaco Capability 0 0 X X
Laser built -in 0 0 0 X
Unit Price $30,000 $6,800 $85,000 $120,000
Pack Price $300 $288 $440-465 $500-600

44. POSSIBLE SOLUTION:
OFFICE PROCEDURE ROOM BASED VITRECTOMY
• Benefits
• Eliminates significant overhead costs
• Example: no need for pre- or post-op registered nurses
• Utilize our own ophthalmic technicians…already “on-the-clock.”
• Facility
• Already “bought-and-paid-for”
• Maximizes utilization of assets
• Global Fee paid to practice (professional fee and facility fee)
• Convenience
• Efficiency
• No anesthesia costs for Payers

45. OFFICE PROCEDURE ROOM BASED VITRECTOMY:
RISKS AND LIMITATIONS AND CONSIDERATIONS
• Patient Safety
• Case limitations
• Financial issues

46. • Endophthalmitis risk
• Mortality risks
• No Anesthesiologist in the event of
cardiovascular event
OFFICE PROCEDURE ROOM BASED VITRECTOMY:
SAFETY

47. • Case Selection Critical!
• No complex cases
• No lengthy cases
• No medically or mentally unstable
patients
OFFICE PROCEDURE ROOM BASED VITRECTOMY:
CASE LIMITATIONS

48. OFFICE PROCEDURE ROOM BASED VITRECTOMY:
FINANCIAL CONSIDERATIONS
• Surgeon fees remain unchanged
• Intangible cost benefits for the surgeon and patient
• Eliminates travel to surgical center
• Not dependent on surgical center availability
• Convenience factor
• Facility charges…
• Conversations with Payors
• Goal: Global fees go entirely to the practice

49. LOCAL PAYER FEES
CPT
Code Code Description Global
Professional
Only
67036 Vitrectomy, Mechanical, pars plana approach $2,954.18 $1,298.53
67040
Vitrectomy, Mechanical, pars plana
approach; with endolaser panretinal
photocoagulation $3,578.76 $1,923.11
67041
Vitrectomy, Mechanical, pars plana
approach; with removal of preretinal cellular
membrane $3,449.29 $1,793.64
67042
Vitrectomy, Mechanical, pars plana
approach; with removal of internal limiting
membrane of retina, including intraocular
tamponade (if performed) $3,705.92 $2,050.27
67043
Vitrectomy, Mechanical, pars plana
approach; with removal of subretinal
membrane, including intraocular tamponade
(if performed) $3,852.16 $2,196.51

50. OVERHEAD CONSIDERATIONS
• Durable expenses and fixed costs
• Disposable costs

51. PROCEDURE ROOM
DURABLE CAPITAL EQUIPMENT COSTS
Capital Equipment .
Vitrectomy Unit (VersaVit, Synergetics) 30,000
Surgical Microscope (Lica) 55,000
Viewing System (Merlin, Volk) 10,000
Autoclave NC
Laser NC
Cryogenic Unit NC
Surgical bed NC
Mayo stand 424.38
Surgical Tray with Instruments 2214.67
Total Capital Initial Cost 97,639.05
Requires industry leaders interested in making such an endeavor succeed.
Example: VersaVit (Synergetics)

52. PROCEDURE ROOM
DURABLE CAPITAL EQUIPMENT COSTS
Surgical Instrument Tray .
Scleral plug forcep 233.00
Troutman needle holder 333.60
Castroviejo needle holder 205.60
Wescott scissor 244.80
Speculum 29.60
Alfonso speculum 60.00
Ten Stevens curved scissor 103.20
Retina hook 66.40
Suture forcep 321.60
Fixation forcep 214.60
Irrigation cannula Autoclavable 20.80
Blunt cannula 18G Disposable 0.23
Scleral depressor 114.40
Lancaster Speculum 89.60
Mosquito hemostat 21.24
Instrument tray 156.00
Total surgical tray cost 2214.67

53. PROCEDURE ROOM
STERILE SUPPLIES COST/CASE
Bouffant cap 0.16
Steri strip 1/2 x 4 1.17
GonioVisc 3.56
BSS 15ml 3.56
Marcaine 0.75 4.17
Lidocaine HCL 2% 3.54
Gentamicin 2 ml 4.17
Kenalog 12.50
Sterilization pouch 7.5 x 13 0.12
Sterilization pouch 3.5 x 9 0.06
Sterilization wrap 0.92
Total cost 86.86
Gloves Prep surgical gloves 0.98
Sterile scrub prep 0.73
Gloves (7 1/2 Ansell Micro Optic) 1.40
Sterile 4x4 pkg of 10 0.62
Iondine cup (autoclavable) 15.00
Providine-Iodine prep solution 1.20
Eye pad 0.16
Eye shield 1.98
U drape 11.26
Sterile drape 18x26 0.25
Back table sterile drape 2.39
Mayo stand cover 2.13
Incise drape 13.50
Sterile prep bulb 0.89
Surgical mask 0.44

54. PROCEDURE ROOM
DISPOSABLE EQUIPMENT COSTS/CASE
Virectomy Disposables For Vitrectomy Only
Balanced Saline Solution 10.00
Efficiency Pack (Cutter and Cassette) 130.00
AGPI (Pressurized Tubing) 31.50
Aspiration Line with 3 way stopcock 10.00
25 Gauge Stealth Trocar Cannulas 71.00
25 Gauge Midfield Light Pipe 24.38
BSS 500 mg 10.00
Total cost/Case 286.88

55. PROCEDURE ROOM
DISPOSABLE EQUIPMENT COSTS/CASE
Virectomy Disposables For Macular Cases
Soft Tip, 25 Gauge 22.00
Flat Lens 30.00
Fine Tip Eckardt Forcep, Disposable 100.00
Balanced Saline Solution 10.00
Efficiency Pack (Cutter and Cassette) 130.00
AGPI (Pressurized Tubing) 31.50
Aspiration Line with 3 way stopcock 10.00
25 Gauge Stealth Trocar Cannulas 71.00
25 Gauge Midfield Light Pipe 24.38
BSS 500 mg 10.00
Total cost/Case 438.88

56. PROCEDURE ROOM VITRECTOMY ECONOMICS
BASED ON SINGLE PRIVATE THIRD PARTY PAYOR
Liabilities Revenues
PPV 2954.18
Sterile supplies 86.86
Disposable Equipment 286.88
Surgeon Fees 1298.53
TOTAL REVENUES 1281.91
CASES REQUIRED TO PAY
OFF CAPITAL COSTS 76

57. “SELECTED CASES”
• Currently
• Vitreous Hemorrhage with retinal tear
• Post-operative vitreous hemorrhage
• Macular Pucker
• Vitreous Biopsy
• Planned
• Non-clearing Symptomatic Vitreous Opacities
• Endophthalmitis
• Uncomplicated Psuedophakic Retinal Detachment
• Uncomplicated Diabetic Vitreous Hemorrhage
• Dropped lens material following complicated cataract surgery amenable to vitrectomy removal

58. • Medically Stable
• Emotionally able to tolerate lightly-
sedated surgical procedure
PATIENT SELECTION

59. OFFICE PROCEDURE ROOM BASED VITRECTOMY
SURGERY SUMMARY
• Feasible
• Profitable
• Requires more investigation
• Patient safety
• Case selection
• Outcomes
• Requires industry collaboration
• Economically beneficial to all parties
• Patients
• Payers
• Physicians

61. • Safe and effective
• User friendly
• Portable
• Lower cost alternative
• Potential areas of use
• Office
• OR second, backup, or
primary unit
• Third world countries as
primary unit
• Mission work
VERSAVIT SUMMARY

62. “STAY THIRSTY”
THINK OUTSIDE THE BOX

63. COST ANALYSIS OF INSTRUMENTATION
CHOICES IN AN AMBULATORY SURGERY
CENTER
• Brandon G. Busbee, MD
• Tennessee Retina
• Nashville, TN

64. USA VITREORETINAL SURGEONS ASC USE OVER PAST 10
YEARS FOR (ASRS PAT SURVEYS)
• First ASRS question for ASC data 2006
• * 2012 ASRS PAT survey data

65. WHERE ARE THE COSTS?
• Turn over time
• Case time
• Disposable instrument use
• Use of oil, PFO, etc.
• Medication use

66. ADDITIONAL (NON-TRADITIONAL)
OR EFFICIENCIES
• Move to an ASC
• Vitrectomy choices
• Viewing choices

67. MERLIN SURGICAL SYSTEM
• Non-contact wide field viewing
system
• 360 rotation of arm
• Reusable lenses
– Large diameter widefield (ora)
– Small diameter widefield (ora)
– Mid field lens (vitreous base)

68. COST MODEL – ASSUMPTIONS
• Retail purchasing of capital equipment
– Versa Vit by Synergetics - $30,000
• Retail purchasing of vitrectomy packs and disposable
lenses
– Retail pack pricing
• Constellation (Alcon) 100%
• Stellaris (B&L) 80%
• Versa Vit (Synergetics) 55%
– BIOM disposable $100 per case

69. •Sensitivity analysis using different case load and usage
– LV/LU - Low case load (200) / Low VersaVit usage (50%)
– LV/HU - Low case load (200) / High Versa Vit usage (75%)
– HV/LU – High case load (300) / Low Versa Vit usage (50%)
– HV/HU - High case load (300) / High Versa Vit usage (75%)
COST MODEL – ASSUMPTIONS

70. COST MODEL – RESULTS VV VS. STELLARIS
• Break even
– Within first year for all cases
• Cost savings over 7 years
– LV/LU: $160k
– LV/HU: $200k
– HV/HU: $330k

71. COST MODEL – RESULTS VV VS. CONSTELLATION
• Break even
– Within first year for all cases
• Cost savings over 7 years
– LV/LU: $250k
– LV/HU: $330k
– HV/HU: $520k

72. ESTIMATED COST REDUCTION:
STELLARIS PC + 1-USE LENS VS. VV + REUSABLE LENS

73. ESTIMATED COST REDUCTION:
CONSTELLATION + 1-USE LENS VS. VV + REUSABLE LENS

74. ASC EVALUATION WITH VERSA VIT
1 WECKCELL ALCON SPEAR 2.56 2.56
1 25G NEEDLE 5/8 0.03 0.03
1 25G VITRECTOMY PACK 350.00 350.00
25 COTTON TIPS 3" INCH WOOD 0.05 1.25
3 3CC SYRINGES W/O NEEDLE 0.04 0.12
2 5CC PLAIN SYRINGES 0.07 0.14
1 25G SOFT TIP 25.00 25.00
1 ENT PACK 21.59 21.59
1 25G AWH CHANDELIER 94.91 94.91
1 NORMAL SALINE 500 ML 1.17 1.17
1 EAR SYRINGE 0.49 0.49
1 1060 DRAPE 3.26 3.26
1 RAYTEK 0.43 0.43
3 30G NEEDLES 0.07 0.21
3 20G NEEDLES 0.03 0.09
1 TB SYRINGE 0.22 0.22
1 MILTEX FILTER 2.52 2.52
1 60CC SYRINGEW/O NEEDLE 0.30 0.30
1 T-TUBE 1.70 1.70
1 RETROBULBAR NEEDLE 3.84 3.84

75. VV / ASC FACILITY SAVINGS BY CODE
• 67042 without gas --- 37% savings
• 67042 with gas --- 32% savings
• 67108 with gas, no buckle – 30% savings
• 67113 with buckle and oil ---- 22% savings

76. SUMMARY
• OR choices are not limited to traditional efficiencies
• ASC can be a game-changer for time and facility margin
• My ASC has increased profits from use of Synergetics Versa Vit
and Volk’s Merlin viewing system

77. HOW WILL I USE THE SYSTEM IN THE ASC?
• Backup unit
• Second unit
• Running 2 rooms
• Second retina surgeon operating
• Consider using as a principle unit for designated cases (no silicone oil or
lens fragmentation required)
• Cost effective packs
• Fast setup
• User friendly

78. HOW WILL I USE THE SYSTEM IN THE OFFICE?
• Initial cases
• Diagnostic vitrectomy
• Non-clearing or postoperative vitreous hemorrhage
• Hemorrhagic PVD without or with tear
• Endophthalmitis
• Next stage
• “Simple” retinal detachments
• Macular pucker
• Macular Hole

79. 25-GAUGE BIMANUAL SURGERY FOR COMPLEX
DIABETIC TRACTION RETINAL DETACHMENT