Since Robert Machemer developed the first vitreous cutter in the early 1970s, instrumentation has moved from 20-gauge systems, the historical standard, to 25-gauge systems introduced in 2002 and, more recently, 27-gauge systems.
Smaller incisions brought improvements in wound construction, operating time, post-operative inflammation, and complication rates. Development has since shifted toward cut rate and fluidics, because higher cut rates fragment vitreous into smaller pieces and reduce traction on the adjacent retina.1
“I migrated to 25, but … as you go up even to 27, you see the efficiency changes with the single port cutters that are available.”
In this episode of Evidence Based Retina, three retina surgeons discuss how recent advances in vitrectomy cutters and fluidics have changed intra-operative pressure control, cutting efficiency, and gauge selection.
Rishi P. Singh, MD, FASRS, hosts the discussion with Ajay Kuriyan, MD, of Mid Atlantic Retina and the Wills Eye Hospital Retina Service, and Sunir Garg, MD, FACS, director of the Retina Service at Mid Atlantic Retina/Wills Eye Hospital.
Bi-Blade+ fast facts
- In April 2026, the FDA granted 510(k) clearance to the Bi-Blade+ dual-port vitrectomy cutter and the Adaptive Fluidics advanced update for the Stellaris Elite system. The cutter is indicated for anterior vitrectomy during anterior segment surgery and for vitreoretinal conditions requiring posterior or combined vitrectomy.2
- Bi-Blade+ reaches 25,000 cuts per minute (cpm) with a dual-port design that doubles the cut rate of single-port cutters while maintaining a 100% duty cycle. It is available in 23-, 25-, and 27-gauge sizes.3,4
- Compared with the original Bi-Blade, Bi-Blade+ demonstrated a 67% increase in cutter speed, 25% greater average vitreous flow, and 62% less vibration at maximum cut speed in ex vivo and in vitro testing.2,4
- Iatrogenic retinal breaks remain a meaningful risk during induced posterior vitreous detachment (PVD). A 2026 retrospective study of 185 eyes undergoing 25- or 27-gauge macular surgery reported breaks in 15.1%, with 69% located inferiorly.5
- Independent clinical data on dual-blade cutters remain limited. A randomized controlled trial compared a 25-gauge 20,000-cpm dual-blade cutter with a 10,000-cpm single-blade cutter:6
- Overall core vitrectomy time did not differ significantly (269 vs. 289 seconds; P = 0.347).
- The dual-blade cutter was significantly faster in epiretinal membrane eyes (241 vs. 291 seconds; P = 0.03).
- No intra-operative iatrogenic breaks occurred in either arm.
How Bi-Blade+ and Adaptive Fluidics stabilize IOP
Intraocular pressure (IOP) is the problem that most often changes early management after vitrectomy. In a Wills Eye cohort of 418 vitrectomies for rhegmatogenous or tractional retinal detachment, every management change at post-operative day one was made to treat elevated IOP.7 Silicone oil tamponade showed a trend toward higher day-one IOP that did not reach statistical significance (relative risk 3.23; P = 0.06).7
When a trainee aspirates balanced salt solution rather than vitreous, fluid leaves the eye faster than many systems replace it, and the eye softens until the console compensates. Dr. Singh, who operates on an older non-Bausch platform, raises his baseline infusion pressure to offset that lag.
Adaptive Fluidics instead adjusts infusion automatically in response to the surgeon’s real-time vacuum commands.2 Dr. Kuriyan, a Stellaris Elite user, sets IOP at 25mmHg for most cases and lower in diabetic eyes at risk of ischemia.
“With the more recent advancements, we’ve been able to compensate for that with Adaptive Fluidics and be able to maintain the pressure in the eye a lot better than in previous iterations of the machine.”
Clinical data on IOP stability during surgery
Paired with Adaptive Fluidics, Bi-Blade+ produced a 62% reduction in average infusion pressure compared with surgery without Adaptive Fluidics. Chamber IOP also stayed closer to the physiologic range of 10 to 20mmHg, even at high vacuum levels.2,8 The continuous aspiration of a 100% duty cycle contributes to that stability.2 With the original Bi-Blade, Adaptive Fluidics cut the drop in operating IOP in half.3
Port design also determines how much suction a surgeon can generate when elevating a firmly adherent hyaloid. Dr. Garg uses the cutter for PVD induction. He also throttles the foot pedal to turn it into a single-action scissor for segmenting and delaminating diabetic membranes.
“I can generate a lot of suction very rapidly, and that helps me be able to peel a [hyaloid] even in cases where it’s really firmly adherent.”
The Bi-Blade+ performance figures come from bench testing and conference abstracts, not from peer-reviewed clinical outcome studies.2,4,8 Whether they translate into fewer iatrogenic breaks or better visual outcomes has not yet been established.
In closing
Current vitrectomy platforms gain efficiency mainly through cut rate, duty cycle, and automated infusion control rather than through smaller incisions. For surgeons evaluating new equipment, the strongest current argument for Bi-Blade+ with Adaptive Fluidics is more stable IOP at high vacuum, and clinical outcome data are the next evidence to watch for.
This article was written by Mariel Mohns, MS, based on the conversation between Drs. Singh, Garg, and Kuriyan.
