Eyeworld

70 | EYEWORLD | MARCH 2020 I ILLUMINATING INTRAOPERATIVE TECHNOLOGIES N FOCUS by Liz Hillman Editorial Co-Director 2014, said he uses 35% illumination with the CONSTELLATION Vision System (Alcon) when operating with a traditional microscope, compared to 5–15% illumination when using digital microscopy. "Lower phototoxicity risk means residents and fellows, who might take longer, get to do more in surgery," Dr. Riemann said. The teaching experience is also better for the attending and the trainee. "It is an up close and personal experience, and a lot of fellows get nervous when operating with staff. For me, being able to sit back, not be in pain while awkwardly straining to look through assistant oculars, looking at the same image, sitting 3–4 feet behind them … it makes for a much better teaching experience," Dr. Riemann said. In any teaching situation, there will be times when the faculty member needs to step in and show the trainee what to do (or perhaps help them if things go awry). With a typical operat- ing microscope, this would require the student to pull back, for the instructor to move into position, and adjust the microscope to their per- sonal pupillary diameter and instrument myopia settings. This, Dr. Riemann said, can take up 30–45 seconds. "In an eye where something isn't going well, 45 seconds is a long time," he said. "But [with a digital screen] I can jump in in about 10 seconds." The screen itself is like a "digital surgical cockpit," Dr. Riemann said. An overlay of ma- chine parameters gives the surgeon vital infor- mation while allowing them to keep their eyes on the surgical field. "Instead of having to ask the tech, 'What is my actual suction right now?' I can look at the screen. It's right there, without a head turn away from the surgical field," he said. Shannon Wong, MD, and Dr. Rubenstein also touted the information that could be avail- able on the screen. "The potential to have image overlays for astigmatism management (e.g., arcuate incision placement), capsulorhexis diameter, intraoper- ative aberrometry, OCT, or topography would S ince January 2019, Jonathan Ruben- stein, MD, has tried to use 3D, digital microscopy almost exclusively for his cataract and anterior segment cases. First and foremost, Dr. Ruben- stein sees a value in 3D viewing systems for teaching. "Residents and anyone else in the room— whether it's residents, medical students, OR staff, nurses, or technicians—can see what's going on, have the same view I have and under- stand the surgery a little better," he said. "For nurses and technicians, it makes them more interested in eye surgery and it also makes them better assistants for me and better help for the patient." He also likes it because, as he put it, it's fun. "New technology always makes surgery a little fresher and more exciting," he said. "You are learning a new perspective about the eye and about surgery because you are using a different visualization system." The transition from a traditional operating microscope to surgery off a screen isn't as awk- ward as you might think, Dr. Rubenstein said. "In my first case using a 3D system, adapt- ing to it wasn't much of a problem at all, and now I like it the more I use it. Right off the bat it was not a hard transition," he said. The NGENUITY 3D Visualization Sys- tem (Alcon), the system Dr. Rubenstein uses, consists of a 3D stereoscopic, high-definition digital camera that's mounted on the surgical microscope. The live imaging is broadcast on a large, high-definition screen in the operating room. Everyone in the room wears 3D glasses and the surgeon operates while looking at the screen. Other 3D visualization systems include TrueVision 3D (Leica Microsystems) and ARTEVO 800 (Carl Zeiss Meditec). Christopher Riemann, MD, a retina spe- cialist who published the first series of screen- based vitreoretinal surgery in 2011, also cited the teaching benefits of digital microscopy. 1 One of these is lower risk for phototoxicity. Dr. Riemann, who has been doing screen-based vitreoretinal surgery almost exclusively since 3D viewing systems: Is it time to upgrade your microscopy? At a glance • 3D digital microscopy has been making inroads in vitreoretinal and anterior segment surgery, but its visualization benefits might depend on the procedure you're doing. • Physicians agree on its value as a teaching tool, providing everyone in the OR with the same view as the surgeon. • Improved ergonomics of this "heads-up" surgery have been touted, but some think that benefit is "overblown." About the doctors Christopher Riemann, MD Director of the Vitreoretinal Fellowship Cincinnati Eye Institute and University of Cincinnati Cincinnati, Ohio Jonathan Rubenstein, MD Deutsch Family Professor of Ophthalmology Rush University Medical Center Chicago, Illinois Shannon Wong, MD Austin Eye Austin, Texas

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