Plasma blade has several applications in

ophthalmic surgery
The blade is approved for use in capsulotomy, iridotomy and transciliary
filtration procedures.
Ocular Surgery News U.S. Edition, December 25, 2009
Richard J. Fugo, MD, PhD

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Ophthalmic surgical incisions can be made using various methods, including

mechanical blades made of steel, diamond or sapphire; radiofrequency;
diathermy; and lasers. More recently, gamma knife radiosurgery has been
used to treat intraocular tumors. The “blades” of the gamma knife are
beams of gamma radiation programmed to target the unwanted lesion. Thomas
John

Unlike the sharp edge of a metal blade or an electrosurgical cutter, a plasma blade
uses pulses of plasma that are generated around its tip to cut and cauterize tissue
without any extensive collateral tissue damage. Added benefits of a plasma blade
include improved wound healing, reduced thermal injury to adjacent tissue and no
excessive bleeding.

In this column, Dr. Richard J. Fugo describes the use of the plasma blade in
ophthalmic surgery.

– Thomas John, MD
OSN Surgical Maneuvers Editor

The plasma blade, also known as the Fugo blade, is the first plasma ablation
system that can create precise low-energy incisions on the ocular surface
and within the human eye. The U.S. Food and Drug Administration has
approved this plasma blade for capsulotomy, iridotomy and transciliary
Richard J. filtration.
Fugo

Plasma blade
The Fugo plasma blade is a portable, battery-powered, solid-state system (Medisurg
Research & Management) that uses C-cell batteries. It conditions the energy in a
portable, solid-state console and then focuses the energy on a blunt hair-thin
ablation/cutting filament. This energy field produces a controllable and visible plasma
column. Histologic studies at the University of South Carolina and Louisiana State
University on the incision walls created by this plasma blade have demonstrated
pristine, clean incision walls based on nanotechnology stripping of tissue molecules,
thereby eliminating the charring or incision wall damage seen in most other standard
electrosurgical systems. Additionally, it produces a non-cauterizing hemostasis and
kills any microbes in the incision path.

Capsulotomy
Plasma blade capsulotomy for cataract surgery was first approved by the FDA in 2000,
and it has provided a unique ability to manage difficult cases, as well as an ability to
surgically manage capsular tears (Figure 1). The resistance-free ablation is invaluable
in cases with weak zonules, dense membranes or small pupils such as in
intraoperative floppy iris syndrome. A plasma blade capsulotomy can be performed
beneath a penetrating keratoplasty graft, and no postoperative graft decompensation
has been reported in more than 10 years with such graft-associated capsulotomies.
Figure 1. Top left: A
round plasma blade
capsulotomy is
performed just inside the
pupillary margin (blue
arrow) within seconds.
Top right: A horizontal
capsular tear is visible
(red arrow). Two
perpendicular vertical
plasma blade ablation
lines are created on
either side of the
horizontal tear (blue
arrows). This prevents
any peripheral extension
of the capsular tear. The
ablation paths on either
side have rounded edges
(no acute angles), and
hence these ablation
paths cannot continue to
tear or run. Bottom left: A
plasma blade
capsulotomy is
performed beneath a
clear penetrating
keratoplasty graft.
Bottom right: A large
capsulotomy is
performed beneath the
iris in an intraoperative
floppy iris syndrome
case, with no direct
visualization of the
capsulotomy tip.
Images: Fugo RJ
Patients with intraoperative floppy iris syndrome can easily be managed by placing the
ablation filament tip under the iris (out of view of the surgeon) and slowly ablating a
360° capsulotomy, after which the nucleus is impaled and pulled into the pupil with the
phaco tip, while the surgeon’s second hand is injecting viscoelastic material behind
the nucleus. Thus, the posterior capsule is pushed back, and the nucleus is held up at
the iris plane by the injected viscoelastic material. The nucleus is then cracked and
phacoemulsified. Thus, the nucleus acts like a pupil expander because it holds the
pupil open. I go beneath the iris with the capsulotomy tip in more than 40% of my
cases.

Iridotomy and pupilloplasty

Iridotomy is performed by placing the ablation tip at the intended site of iridotomy, and
the tip is activated for a second or two, thereby creating a bloodless iridotomy. The
size of the iridotomy is under surgeon control. Such an iridotomy can be placed far out
in the periphery adjacent to the iris root and can be useful in Visian implantable
Collamer lens (STAAR Surgical) surgery. The plasma blade is also useful in performing
pupilloplasty (Figure 2).

Figure 2. Tracing the

blunt plasma blade probe
over the iris in this
bound-down pupil in a
counterclockwise circle
creates a cosmetically
perfect bloodless pupil.
 Figure 3. Transciliary
filtration requires a
precise plasma ostomy
created by plasma
ablation into the
posterior chamber and
rarely produces a
postoperative flat
anterior chamber.

Transciliary filtration
Transciliary filtration (TCF) or Singh filtration — Dr. Daljit Singh in India first described
TCF — drains aqueous from behind the iris, ie, from the posterior chamber (Figure 3).
This is the first FDA-approved retro-iris filtration procedure.

TCF may be considered to change the paradigm of filtering surgery. In more than 5,000
cases worldwide, there has been only one reported case of a flat anterior chamber. By
filtering aqueous from the posterior chamber, the force vectors pushing against the
back surface of the iris are reduced lower than the force vectors pushing against the
front surface of the iris. Therefore, the force vectors pushing the iris forward are
always lower than the force vectors pushing the iris backward, making it near
impossible for the iris to flatten against the cornea. In my 8 years of experience with
TCF, I have yet to see a single flat anterior chamber postoperatively.

After a simple conjunctival flap, a 30-second transillumination of the anterior chamber

with the surgical microscope allows the exact location to plasma-ablate into the
posterior chamber of the eye. Aqueous flow from the ablation pore is thought to be
auto-regulated as the flaccid finger processes of the pars plicata are presumed to
temporarily herniate into the filtration pore as the eye softens and are then presumed
to pull out of the pore as the IOP begins to increase and the finger processes become
rigid and tense. Theoretically, this auto-regulatory cycle is believed to repeat as the IOP
increases and decreases. A watertight seal is not needed, and hence, only two or three
conjunctival sutures are placed at the limbus.
The TCF procedure can be performed under topical anesthesia. A 1-minute exposure
of mitomycin C is often useful. A recent approach has been the combination of
plasma ablation trabeculectomy and TCF, with early promising results as per Dr. Amar
Atwal, of Buffalo, N.Y.

References:

Fugo RJ, DelCampo DM. The Fugo Blade: the next step after capsulorhexis.
Ann Ophthalmol. 2001;33(1):12-20.
Peponis V, Rosenberg P, Reddy SV, Herz JB, Kaufman HE. The use of the
Fugo Blade in corneal surgery: a preliminary animal study. Cornea.
2006;25(2):206-208.
Trivedi RH, Wilson ME Jr, Bartholomew LR. Extensibility and scanning
electron microscopy evaluation of 5 pediatric anterior capsulotomy
techniques in a porcine model. J Cataract Refract Surg. 2006;32(7):1206-
1213.
Singh D, Singh K. Transciliary filtration using the Fugo Blade. Ann
Ophthalmol. 2002;34(3):183-187.

Thomas John, MD, is a clinical associate professor at Loyola University at

Chicago and is in private practice in Tinley Park and Oak Lawn, Ill. He can
be reached at 708-429-2223; fax: 708-429-2226; e-mail:
[email protected].
Richard J. Fugo, MD, PhD, can be reached at the Medisurg Research &
Management, 100 W. Fornance St., Norristown, PA 19401; 610-279-5550; e-
mail: [email protected]. Dr. Fugo has a direct financial interest in the
Fugo Blade and is a stockholder in Medisurg.

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