Professor Ferenc Kuhn

The new Vitreq 23 Gauge Eckardt Forceps is the best forceps I have ever had in my hand. The design is aesthetically beautiful; the box for sterilization is very practical. The forceps is easy to handle, the force needed is just right - not too much and not too little resistance. The grabbing is secure, the platform is large enough to hold the tissue securely, yet it is small enough to allow the surgeon to actually see what is being grabbed. I must have performed ILM peeling in well over 5,000 cases in my career; this is by far the BEST forceps I have ever worked with! - Professor Ferenc Kuhn.

Professor Ferenc Kuhn is one of the world`s top experts in retinal diseases and the treatment of eye damage. He is associate Professor of Ophthalmology at the University of Alabama in the United States (US), President of the International Society of Ocular Trauma, immediate Past President of the American Society of Ocular Trauma, the Director of Clinical Research at the Helen Keller Foundation in the US, and a Professor at the University of Pecs, in Hungary. He has received numerous prestigious international awards.

Which instrument do you most value and which features make this instrument so effective?

I can’t say that I have one favorite instrument. A lot of it depends on how conscious-a-surgeon you are. I am a very conscious surgeon. I almost never do anything by reflex, or because somebody said so, or because somebody showed it to me, unless in a conscious thought process, I could see the benefit. What that means is that you can do a lot more with a lot fewer instruments. But if I have to pick two, one is a pair of scissors - I prefer vertical scissors as they allow two different surgical manipulations: cutting, of course, but it also use as a spatula to create space, so you don’t have to replace one instrument with the other to get to where you want to be. The other one is an instrument that is not usually produced by the industry, because it is so simple. This is a blade or a needle, with the tip bent a little bit (at roughly a 30 degree angle to the shaft), to find and to lift membranes. It can be turned towards or away from the retina. When it’s away from the retina, you can also use it as a spatula, or even for some very primitive cutting. So again, it’s a combination of several instruments within something very simple.

Which instrument or procedure currently proves the most challenging to you in your daily practice? And what could be improved?

I do a lot of very difficult trauma cases. The biggest challenge comes from the fact that I mostly see these patients very late, when you not only have the immediate consequences of the injury, but also later complications, which could have been avoided by going in earlier. It is also very variable - you have to use your brain a lot, not just your hands! Surgically, one of the most complicated cases we face is from a diabetic, who had surgery usually for tractional retinal detachment and then as a complication he or she develops PVR, which is in itself a difficult condition to treat. Normally PVR forms in an eye with a healthy retina; the diabetic retina is not. So surgical maneuvers that the healthy retina tolerates, this retina does not. In PVR surgery, you have to remove membranes that are stuck to the retina, so that requires some traction to be exerted on the retina. Most of the time, the retina doesn’t suffer from that, but the diabetic retina does. So the job is doubly or triply more complicated and requires a lot more delicate manipulations. Here, the real advantage comes in doing bi-manual surgery, which means the light is not in your hands, as in most other cases, but somewhere fixed to the eye wall. That is one area where improvement could help, because when you have the light in your hand you can do a lot of things with it: change the angle, change how close you are to where you work etc. etc., but with the light source fixed to the wall you are a lot more limited in how you light up your surgical field. I have tried several designs of existing light sources and cannot say that I have seen the optimal one yet. There are a few things which need to be worked out to make it ideal or close to ideal.

What experience have you had of working directly with companies to develop new instruments and/or surgical techniques? What are the benefits and/or limitations of working directly with companies?

I did develop a couple of instruments that went into production. And I abandoned a lot more, because the problem with larger companies is that there are so many layers that to go from idea even to prototype, much less from prototype to production is a very difficult process, in which you need to be very persistent and also have patience and time. One thing that I have always looked for is a company, in which you don’t have those layers. Where there are people who are open to new ideas and are willing to accept the fact that when you come out with something dramatically new, it’s not going to be profitable the next morning, because people will take time to accept, to adjust to it. There is a lag between manufacturing and profit. New things will not be accepted and profitable overnight.

What do you expect to see developing in the future (e.g. the next 3-5 years) in VR surgery?

To have a light that I am very comfortable not having in my hand to make bi-manual surgery more a routine than it currently is. For example, having it built into the infusion cannula, which we always have in the eye anyway, and not require a separate incision to put it into the eye. I think it would be really amazing. Another thing is the peer pressure that we experience to go to smaller and smaller gauge instruments. We went from 20 gauge, to 23 gauge, 25 gauge and now 27 gauge. I am not convinced that it’s a limitless process, because each downsizing has disadvantages. It becomes slower, certain things cannot be done, it will take time for technology to catch up and offer everything in a smaller instrument gauge, etc. I am not convinced the benefits are so much greater with smaller sizes. Maybe it’s better to stick with one gauge, whether 23 or 25, when everything that has been available with 20 gauge, will be available, and do so without compromising something else. One of the compromises that we are currently experiencing is how flexible the instruments are - The smaller the gauge, the more flexible. As a principle, you don’t want to fight an instrument during surgery; you want to fight the disease. To strengthen the current instrumentation, to me, would be more important than going to another smaller gauge.

What are your own priority focus areas for the next few years- either in research or clinical practice?

I am looking still for a company for my ideas, which is small enough, innovative enough and long-term focused enough. I have a good relationship with Frank. We have worked together before for many years. The company is small enough not only to be forced to listen to the surgeon, but to have the personal dedication to do so. That’s very important.

Do you think that Vitreq instrumentation will be valuable in your own work in the future?

I am sure the quality is as high as you would expect. They have had some great ideas already –the handle, for example. When you perform very fine maneuvers, and put the forceps in the eye before use, there is a certain distance between the jaws of the forceps, but the tissue you that are grabbing has a much smaller diameter than the forceps opening itself. To eliminate unnecessary movements during the grasping moment, you squeeze the handle beforehand, so that the distance of travel is reduced. Some companies make disposable instruments, in which the travel distance is greater than with a permanent, non-disposable instrument and you have to squeeze even harder. This abuses the very fine muscles of the fingers, putting too much stress on them. And if it’s a longer process or surgery, the surgeon’s hand can develop a tremor, just because he had to squeeze too long and/or hard to prepare the forceps for use. It’s very important thing to ensure that you don’t make it too hard to squeeze and you don’t force the travel to be too large by design. Having exactly the same configuration of the handle for all instruments according to these guidelines, to me, is also just rational, and that’s one of the things Vitreq has also realized.

What do you envisage Vitreq’s role in the market to be?

I see every element of the correct approach to customers at Vitreq. Their hand instruments are as functional as beautiful; they are very, very well designed and this is matched by their functionality. I have known the people at Vitreq for a long time. I know their attitude. Vitreq is open to new ideas. They stand behind their products, which is a very important thing - it’s not a onetime deal when you buy instruments from companies and continual service regarding instruments that you have already bought is important.