The document describes an advanced VR (vitreoretinal) surgery course that includes: 1) Theory sessions and wetlab practice using modern vitrectomy units with microincisional surgery options. 2) Practice using pig eyes, synthetic eye models, and a computerized training simulator. 3) Steps for wetlab vitrectomy practice and simulator training are outlined. 4) Modern technologies for vitrectomy including wide-angle viewing systems, integrated infusion pressure control, and advanced vitrectomy probes are reviewed.

1. The Setup of advanced VR course
E. Parikakis1 – A. Nikolakopoulos2
1 “Ophthalmiatreio” Eye Hospital, Athens, Greece
2 “ G. Papanikolaou” Gen. Hospital ,Thessaloniki, Greece

2. The Setup of Advanced VR Course
 Theory sessions
 Surgical Wetlabs with modern vitrectomy units –
microincisional surgery (23,25,27 gauge) –operating
microscore & wide angle viewing systems
 Practice in pig-eyes and Synthetic eye model
(artificial eye)
 Practice in computerized training simulator
 Retina Dry labs

3. Step by step wetlab vitrectomy
 Fluidics and observation systems
 Sclerotomies (trocars) and fixation of infusion line
 Removal of central vitreous (~ hemmorrhage)
 (Indentation) & removal of peripheral vitreous
 Injection of PFCL and exchage to air / BSS
 P. P. Lensectomy
 Removal of lens fragments ± PFCL
 Management of dislocated IOLs
 Silicone oil in and out
 Removal of IOFB (trauma)
 Struggling with RD (including scleral buckle)
 ILM removal (& artificial eyes)

4. Step by step training in Simulator
 Posterior vitreous detachment induction
 Epiretinal membrane removal
 ILM peeling
 Endolaser training
 Forceps / vitrector training
 Supervised practice on virtual reality simulator
gives realistic hand on surgical experience
 Allows unlimited practice and repetition
 There are customized difficulty levels (training
modules for the beginner and advanced modules
for the expert)

5. 1. Vitrectomy Units - IOP Control
 Increase IOP to control hemorrhage
 Decrease IOP in retina ischaemia, glaucoma
 Some problems in rapid IOP control, open
sclerotomies, aspiration, bottle change
1.1. GravitGravityy systemsystem (bottle height)

6. 2. VGFI System
(vented gas forced infusion)
2.2. VGFI SystemVGFI System
(vented gas forced infusion)
Alcon
Alcon
2500cpm Cut Rate
2500
Wet Ant Prop Vac
VIT: Proportional Vacuum
32
BSS
Air
Applied pressure=32mmHg
IOP = ? mmHg
Pressure
Drop?
Flow variationsFlow variations
““HypotonyHypotony””
 Infusion bottle in certain height
 Pressing the footpetal to raise the pressure to air >
raise pressure to bottle > raise pressure to eye

7. 3. Compensated IOP3.3. Compensated IOPCompensated IOP
BSS
True IOP = 30 (±2) mmHg
IOP Setpoint = 30mmHg
T(sec)
P(mmHg)
PCassette (inside
infusion chamber)
PIOP (inside
the eye)
Flow Compensated IOP

8. Alcon
LuxOR LX3
&Q-VUE
Modern microscope technology & iOCT,
3D
Leica M844
F40 –(3D)
Haag-Streit
Hi-R 900A &
iOCT
Zeiss
Lumera 700
& Rescan 700
TrueVision
Stereoscopic high-definition
visualization system that display the
surgical field of view in real time on a
3D flat panel display in the OR.

9. Wide angle viewing systems (WAVs)
• WAVs are necessary for fundus visualization - are based
on the indirect ophthalmoscopic principle.
• Modern WAVs enhance surgeons’ manipulative abilities by
providing a wide field of view and H-R fundus images.
Zeiss Resight 700
Haag-Streit EIBOS 2
Oculus Biom Ready

10. Wetlab Vitrectomy Tips
 Prepare your case and make yourself comfortable
(chair, fix your microscope, lower magnification =
greater depth of field, lay your instruments down with
order, check the vitrectomy unit)
 Refocus as often as necessary
 Soft pig-eyes globes can be restored with saline
injection
 Pin the globe down for stability
 If the visibility is poor, you can scrap the
epithelium to improve it (or 15% dextran)
 Remember that vitrectomy is a multitasking
procedure (it involves both feet and hands, vision
and hearing)
 Before leave, make sure you have clean
everything, so the next person will find a nice and
clean working place

11. The Setup of advanced VR course
E. Parikakis – A. Nikolakopoulos
Thank you !

12.  Το σύστημα έγχυσης ελέγχει με αισθητήρες την
είσοδο από την έγχυση και την έξοδο από την
αναρρόφηση και ρυθμίζει αυτόματα
 Δυνατότητα για το χειρουργό να καθορίζει την IOP
«Set and Forget »
 Σταθερές ενδοφθάλμιες πιέσεις, όχι υποτονίες
 Επιτρέπει χειρουργείο με χαμηλές πιέσεις
 Σταθερότητα σε αλλαγή μποτίλιας
«On-fly Bottle Change»
3. Integrated pressurized infusion
– «πραγματικός» έλεγχος IOP

13. IOP Control
• IOP control maintains pressure in the eye to + 2
mmHg of what is at console
• Constellation® infusion system automatically
adjusts for the infusion tubing and cannula
pressure drop which occurs when fluid is flowing
through the cannula.
• Compensates for the Infusion Cannula Pressure
Drop is in Real Time
• Provides a Constant IOP during Surgery

14. Σύγχρονη τεχνολογία- Εξέλιξη των probes
Initial 25 ga instruments excessively flexible
Difficult to trim peripheral gel and perform
peripheral endoLASER
As instumentation became more rigid →
additional surgical indications became possible
25- & 23 ga cutter mouth is closer to the end →
more controlled segmentation (multifunctionality)

15.  EndoLASER, Perflurocarbon liquids
 Wide-angle viewing systems, Improved illuminating systems (Xenon)
 25g & 23g transconjunctival sutureless microincision vitrectomy (MIVS)
 High speed vitrectomy probe of 7.500 cpm with duty cycle control
“True” IOP control – pressurized infusion, Valved cannula systems
 27+G Vitrectomy