Professor Tom Williamson is a leading Consultant Ophthalmologist and Vitreoretinal Specialist based in London, UK. He trained in Aberdeen, Cambridge, Glasgow and London and has more than 28 years experience in the care of the eye and 20 years as a vitreoretinal specialist. Tom currently attends Guy’s and St Thomas' Hospitals, The London Clinic, in London, and Queen Mary's Hospital, in Kent, UK. He also has a regular private clinic at The London Claremont Clinic. Tom has over 160 publications on clinical topics in vitreoretinal surgery and ophthalmology. His book, entitled: 'Vitreoretinal Surgery' is the premier text for training in vitreoretinal surgery internationally.  Patients attend his practices from all over the world. He is also a founder of the EyeHope charity, through which, he hopes to support research, teaching and training in eye diseases.

Could you outline your experiences with currently available surgical instrumentation and some of the challenges and opportunities that are relevant for you now and in the future in your VR surgery?

Instruments: A big change that’s happened in VR surgery is that a lot more surgery can now be done with the cutter, whereas in the past, we relied a lot on scissors and forceps. We tend to do a lot more just with the cutter, as these systems have become smaller and the cut rates have gone up: aspirating; cutting close to the retina; dissecting etc. I am slightly surprised that I find a lot of things easier with them. I don’t use a lot of different instruments, but I insist on quality in the ones that I have. My standard instruments are: an end-gripping forceps; a serrated forceps; angled scissor; and very occasionally, a vertical scissor. I used to use vertical scissors a lot, but hardly use that now, because I use the cutter instead.

I have used all sorts of different instruments: it’s not always what you think will work well, it’s what you like. An Eckardt-style end-gripping forceps is a mainstay. It is probably the one extra instrument I use the most. Handle design is important for me. I am not very keen on the basket design end-gripping forceps, even though it can be used in any direction. Essentially, for an end-gripping forceps, you use the instrument in one main direction, and I just find the basket design too ‘woolly’ for me. There is a spring in the system before you close the handle, which I don’t like. I like to know immediately what’s going to happen. So my preferred design has just the two hands that come together, rather than a basket. I know other surgeons love the basket design, because they can rotate it around, but personally, I just don’t like that lack of immediacy.

And curiously, for an Eckardt forceps, the tips are important. I find certain quality brands are far too smooth, which is odd, because they are probably better machined than many of the cheaper ones. They make them very, very smooth on the tip, but I find that the problem with them being very, very smooth is that they don’t grip the ILM. You slip off the ILM just at the moment when you want to grip it. You need just the tiniest bit of roughness on the end of the forceps to make it slightly grasp the tissue. I stopped using these smooth versions, and I went to another system, which was actually more roughly made. For Eckardt’s, manufacturers have been aiming to make them as smooth as possible, but for me, that’s not what I want. It just doesn’t work as well. Serrated forceps are useful in lots of different scenarios, mostly when you’re working with big thick membranes.

The delamination curved or 45 degree scissor – again, if it’s too sharp, is not so good, if it’s a little bit blunt, its better -  you want it sharp in the blade so that you cut the membrane, but not too sharp at the tips, because then you risk doing things in the retina that you don’t want to do.

Illumination: There’s a big shift to bi-manual for me. With bi-manual, I need a chandelier of some sort. I have tried quite a few chandeliers – double- and single chandeliers. I now use the single ones that are trocar-based, so I have a nice stable base to the chandelier. It’s easy to insert. The trocar sits there and the light pipe is better if it’s not too fine and a little bit stiff, so that you can get it to the angle you want and get it to stay there. If it is too floppy, even during the operation, they can move around and you will end up not being able to see everything that you need to. And a lot of them have a slight problem in getting enough light into the eye. I work on a lot of Afro-Caribbean patients with pigmented fundi, and that makes a big, big difference with the chandelier, it’s much, much harder, because all the light is absorbed rather than reflected. So, more light for specific patients is important.

Laser probes: For bi-manual surgery – the other possibility is illuminated laser probes.  I’ve tried lots of laser probes. I have a ‘pet hate’ for laser probes that you advance and retract, especially the ones where the handle goes down the ‘wrong way’, so you move down to retract. I find that I don’t need to advance or retract the laser probe. The nicest laser probes that I use are the ones that are fixed curved. They have a nice fine tip on them. I put the probe through the trocar and, because it is curved, I can work on the whole retina with that. Illuminated laser probes are useful, if I want to not have to put a chandelier in and I want to do more with peripheral laser for diabetics etc. The quality of the light from them is reasonable, but not fantastic. The quality of the laser from them is 50 % less than it should be, so you have to make sure the power is up. They’re OK, but not as nice as using two different instruments. So, obviously there is an opportunity for improvement there.

Trocars: I work with 25 Gauge, as much as I can. I like a flat blade with an angle on it, you put it through the sclera and it never leaks, it’s absolutely fantastic. Some blades are too easy to put in, and don’t seal the wound. In general, I don’t think trocar blades are advanced enough in their development.  

Indenters: For a long time, I have wanted someone to make a decent indenter for surgical use. I don’t know if everybody does it worldwide, but in the UK, we always indent the patient at the end of the operation to push the retina into view. We tend to use squint hooks or the things that take the trocars out (plug pullers). Neither of them is right. The squint hook is 90 degrees, when you actually want it to be 45 degrees. You want it not quite as long as a squint hook. You want it about two thirds of the length of a squint hook, with a little angle on it, nice and smooth, so that when you rub the conjunctiva you don’t tear anything. For surgery, it must be smooth, so that you can indent and get the angle just right. With 45 degrees you can get in and indent very nicely. It’s such a relatively simple piece of kit to make. For years I was not able to convince anybody to make it for me. I spoke to Vitreq about it. They organized for their design team to create some  computer assisted designs and within a couple of months I have a prototype to try. It is attention to detail, which has moved our surgery forward. Even for a simple instrument like an indenter, why use an instrument designed for something else? After all, we do that surgical step for every single patient and it’s a very important part of the operation.

Silicone oils: I use standard silicone oils in general. I’d quite like to use 2000 silicone oil, which has less viscosity than the 5000 versions. I don’t like heavy oils. I use the usual gasses but I believe we can innovate there too.

Cutters: I use a 25 Gauge Alcon cutter. It is OK. Sometimes you have to adjust the cut rates. I like the idea of double cut technology, but I’ve never used it.

Disposables: We use entirely disposable in the UK now following concerns about prion transmission. At the time, when we moved to disposables, I thought it was going to be a problem, and that the equipment would not be good enough, but it has not been like that.

Contact lenses for vitrectomy: For membrane operations, I use contact lenses. They’re OK. I think there are opportunities for innovations to make contact lens fit better when they are inserted. Big lenses, which are traditionally used, are not perfect, because they get pushed out the way by the trocars, and you end up having to re-sit the lenses. It’s not a big deal, but you’d rather not have to do that. I see that Vitreq has very, very small lenses, which might sit right on the cornea and avoid this problem. It would be interesting to try. I don’t think other manufacturers have moved the contact lens design on, since we started using trocars.

Packaging: We tend to use surgical packs. However, there is still quite a lot of instrumentation we use outside of that. Cutters and light pipes are a little bit tricky for us to change practice with. For all the incidental instruments, its ‘open house’ really as to what we use.

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

I definitely will take a detailed look. They certainly have the kind of handle that I like.

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

Vitreq management has a fantastic reputation in instruments and delivery. If they are creating the same level of quality now as they previously have, then I will certainly consider their products. The approachability of Vitreq and their openness to ideas makes them a highly attractive company to deal with.