Following years of incremental steps in the improvement of microscopes for ophthalmic surgery, the latest round of advances feels like a leap. “Ready for prime time” digital and digitally assisted microscopes are making their way into ASCs, bringing with them an array of new capabilities for anterior and posterior segment surgery. Surgeons are enthusiastic about the known and potential benefits for their patients, themselves, and their facilities.

Integration with Other Technologies

Surgical guidance systems are among the first ways microscopes were married with digital capabilities. Data captured in the office for procedure planning, such as biometry and toric IOL alignment for cataract surgery, can be seamlessly transferred to the OR, where it appears in the microscope oculars and/or on an external screen. Similar microscope-integrated digital overlays also convey live, real-time information, such as aberrometry readings and operating parameters from phaco and vitrectomy platforms.

“All sorts of digital integration is happening with microscopes,” says Robert Weinstock, MD, director of cataract and refractive surgery at The Eye Institute of West Florida and Weinstock Laser Eye Center and medical director of the Largo Ambulatory Surgery Center. “The integration of digital information onto the surgical field, so to speak, is a huge advantage. The surgeon doesn’t need to interrupt the procedure to look at different machines to get information. The microscope oculars or an HD monitor become a hub of data. There is a tremendous amount of opportunity for using real-time information in this way to help surgeons be more efficient and safer as they operate.”

Some microscopes already integrate with real-time OCT, which adds a new dimension to the surgeon’s perspective. Corneal and retinal surgeons can see details associated with ocular structures that they wouldn’t typically see during a procedure. In a 3-year study evaluating microscope-integrated intraoperative OCT, anterior and posterior surgeons alike reported the technology had an impact on their intraoperative decision-making, often altering the surgical plan.^1,2

Grab Your 3D Glasses

The recent integration of microscopes with mature digital camera technology has been a jaw-dropper. Fully digital or digitally assisted systems provide stereoscopic images of the surgical field that can be magnified to fill 50-inch-plus, high-definition 3D monitors, while maintaining field of view. While the advanced optics of today’s traditional microscopes provide better-than-ever magnification and field of view, their combination with 3D visualization is often described as immersive.

“With advancements in computer chip technology, computer transmission speed, and 3D digital displays, the view of the surgical field with the new systems is now as good as we see through a traditional microscope,” says Dr. Weinstock.

Elizabeth Yeu, MD, a cornea, cataract, and refractive surgery specialist and partner at Virginia Eye Consultants, agrees.

“Now that lag time is not an issue, the quality of what we can see with a 3D microscope system is unparalleled,” she says. “The magnified image on the monitor actually appears more truly 3D than the view directly down through traditional microscope oculars.”

Dr. Weinstock further describes how the 3D digital viewing systems affect the surgical experience.

“Anterior segment surgeons will notice that they can operate under high magnification without asthenopia,” he explains. “This is an advantage any time I need to perform a challenging maneuver, a tricky capsulorhexis, cortical material removal, and so on. Many other digital settings can be utilized to augment the image and highlight different structures. Contrast, hue, saturation, and the gain on illumination all can be adjusted to improve visualization. Our retina colleagues are even farther ahead in adopting this technology. Their surgeries, on average, are longer than most cataract surgeries, and they sometimes need even higher magnification. They see how much easier it is to work under high magnification with a 3D system compared with looking through the microscope oculars.”

Truly Heads-up Surgery

Not only does the unprecedented visualization provided by 3D microscope systems give surgeons visual comfort, it is also ergonomic.

“They’re truly heads-up,” Dr. Yeu says. “We’ve been able to work somewhat heads-up for a while, depending on a particular microscope’s configuration, but the patient is still in the way. The oculars can tilt only so far. We still have to lean in and can shift away only so far without losing the area of focus. The daily discomfort and long-term neck and back problems caused by this awkward positioning are a real issue in our field.”

Dr. Yeu recently gave a presentation to ophthalmic surgeons on ergonomics. She asked the 600-person audience whether they had back problems that concerned them — and two-thirds raised their hands.

“I recently spent a day trialing a 3D heads-up microscope system. The view and the setup are different at first, but I was able to sit in a normal position and work all day with my back against the back rest of the chair,” notes Dr. Yeu. “At the end of the day, I was much more comfortable than usual. I had less upper back/interscapular discomfort.”

Dr. Weinstock has been operating 100% 3D and heads-up for 2 years with excellent results, and suspects that more comfortable surgeons will ultimately lead to safer surgery for patients.

“If you’re having surgery, you want your surgeon to be relaxed and comfortable, not in an uncomfortable, painful position that causes him or her to lose concentration or be in a hurry to get out of that position,” he notes. Recently, he retrospectively analyzed a series of 2,320 cataract surgeries he performed using either a 3D display system or a traditional binocular microscope.

“Operating heads-up did not delay my surgery time or cause an increase in complications,” he says.³ “This large series shows that heads-up surgery is viable and at least as safe and efficient as surgery through oculars. My instincts tell me that, over time, as we study this more and technology continues to improve, it will prove itself to be safer and more efficient.”

Benefits for the ASC

As far as the impact digitally enhanced microscopes can have on an ASC, for starters, today’s models are more streamlined. The footprints tend to be smaller, and there’s less extra hardware and fewer wires in the OR. The latest viewing systems may also have a direct benefit for an ASC’s patients. Because the surgeon can have ideal brightness with lower light, patients are likely to be more comfortable.

Drs. Weinstock and Yeu cite other benefits as well:

► Efficiency: “Having confidence in my view allows me to be a more efficient surgeon,” Dr. Yeu says. “I can gauge my depth posteriorly with precision, which allows me to be aggressive and safe at the same time. The new microscopes require far less zooming in and out to maintain the desired focus.”

Indeed, 3D systems in particular enhance efficiency for the whole OR team, Dr. Weinstock says.

“There’s a tremendous efficiency component because everybody can see the monitor,” he explains. “It’s good for high-efficiency turnover. Everyone knows where the surgeon is in the case, so they can prepare for what’s coming next. I get the items or assistance I need quickly. If I run into a complication, I may not even have to say anything, because the scrub tech and the circulator already see what’s going on. Less verbal communication is necessary overall.”

► An improved teaching environment: With a 3D system, “I’m able to supervise fellows in a very comfortable way,” Dr. Weinstock says.

“Instead of having to scrub in and wedge myself into a second set of oculars with my eyes correctly positioned, which is challenging and cumbersome, I can stand behind them and watch the monitor to guide them through their surgeries,” he says. “I sense it makes their learning curve shorter, too.”

► Higher profile, more collaboration for the surgery center: A 3D visualization system has brought positive attention to Dr. Weinstock’s ASC. “Other surgeons and optometrists come to watch the 3D surgeries, which raises our profile as a center that offers the best technology available,” he says. “It also makes us a destination for industry. Representatives come in to see how their products are working. They see exactly what I see. We all learn more from procedures because of the view, and we can collaborate more effectively on improvements and innovation.”

► Balanced surgeon workforce: “The next generation of surgeons will seek out ASCs that are high-tech,” says Dr. Weinstock. “They live a digital life; they’re multitaskers. Digitally integrated microscopes allow them to multitask with information on the screen, make decisions on the table, manipulate astigmatism, view OCT scans simultaneously, and so on. Surgery is becoming a different game, and tools such as these microscopes are at the center of it.”

At the same time, says Dr. Yeu, “Growth in the aging population has led to a huge increased need for cataract surgery, which must be performed by a currently decreasing number of surgeons. True heads-up surgery mitigates the physically limiting conditions that occur as a result of our work and, as such, has the potential to increase career longevity.”

SCOPING OUT THE MARKET

Today’s surgical microscopes offer surgeons and their teams a better surgical experience. Here, a look at the latest offerings on the market.

TrueVision 3D Visualization

The M822, M844, and Proveo 8 with integrated TrueVision 3D visualization deliver a new perspective for anterior and posterior surgery. The high-definition screen delivers excellent depth perception and a large field of view. With minute anatomical details visualized on such a large scale, surgery becomes an even more immersive experience. The entire surgical team can share the same real-time, 3D view of the surgical field, improving communication and workflow. The screen can be positioned to support a comfortable, upright position.

With less physical distraction, the surgeon can remain fully focused on achieving optimal patient outcomes.

► For more information, visit leica-microsystems.com

LuxOR Revalia

Alcon’s new LuxOR Revalia Ophthalmic Microscope delivers enhanced visualization during all stages of cataract surgery through unique and personalized LED illumination technology.¹ The NGENUITY 3D Visualization System is now available in the Cataract Refractive Suite to bring 3D visualization for the anterior space.² In addition to offering greater depth of focus during cataract surgery, the system enables a full view of the surgical procedure for the entire OR staff, and enhances training and teaching capabilities for residents and fellows. It also allows the surgeon to operate with a more ergonomic posture during surgery.³

► For more information, visit new.myalcon.com/professional

Hi-R NEO 900

Haag-Streit delivers versatility and precision in microscope technology for ophthalmology, leveraging the company’s strength, experience, and knowledge to produce surgical microscopes that set the standard for optics, ergonomics, engineering, and imaging. Suited for both anterior and posterior segment surgery, the Hi-R NEO 900 microscope features crisp, clear visualization, unsurpassed depth of field, and C.RED reflex technology. The ergonomic design of the Hi-R NEO 900 promotes a healthier alignment of your neck and spine, thereby reducing strain and inefficiency. The vertiscope extends the binoculars to the surgeon, enabling him or her to maintain an upright and relaxed posture and work more efficiently and effectively.

►For more information, visit haag-streit.com

ARTEVO 800 Digital Visualization Platform

The ZEISS ARTEVO 800 Digital Visualization Platform is the first digital microscope in ophthalmic surgery. It was developed with surgeons, for surgeons, with a goal of changing the future of surgical care by revolutionizing visualization, information, comfort and workflow in the operating room. ARTEVO 800 comes with a new feature called “DigitalOptics,” which provides excellent depth of field, reduced light intensity requirements, and real color impression for increased certainty. It also provides digital assistance and detailed information to surgical vision in real time. In addition, ARTEVO 800 comes with cloud connectivity to the ZEISS Cataract Suite, allowing surgeons to access patient data remotely.

► For more information, visit zeiss.com

REFERENCES

1. Alcon Data on File.
2. Alcon Data on File. Yin L, Sarangapani R. Assessment of visual attributes for NGENUITY^® 3D Visualization System 1.0 for digitally assisted vitreoretinal surgery. Alcon Modeling and Simulation. December 2017.
3. Eckardt C, Paulo EB. Heads-up surgery for vitreoretinal procedures: an experimental and clinical study. Retina. 2016;36(1):137-147.

Welcome to the Future

Surgical microscopes are now officially immersed in the digital revolution, making the potential for even more interesting and useful capabilities practically limitless. Dr. Weinstock says surgeons can expect all types of intelligent advances, such as microscope-integrated automatic tracking that keeps the eye centered without the need to use a foot pedal.

“The surgical microscope of today and the future is digitally enhanced,” he says. “Instead of a straight optical view, we have enhancement of the optical image by computers and 3D visualization systems, surgeon-controlled optimization, and application of previously segregated information. So much more can be done with the added digital capability.” ■

REFERENCES

1. Ehlers JP, Modi YS, Pecen PE, et al. The DISCOVER study 3-year results: feasibility and usefulness of microscope-integrated intraoperative OCT during ophthalmic surgery. Ophthalmology. 2018;125(7):1014-1027.
2. Khan M, Srivastava SK, Reese JL, Shwani Z, Ehlers JP. Intraoperative OCT-assisted surgery for proliferative diabetic retinopathy in the DISCOVER study. Ophthalmol Retina. 2018;2:411-417.
3. Weinstock RJ, Diakonis VF, Schwartz AJ, Weinstock AJ. Heads-up cataract surgery: complication rates, surgical duration, and comparison with traditional microscopes. J Refract Surg. 2019;35(5):318-322.