ASIA-PACIFIC’S FIRST MAGAZINE ON THE POSTERIOR SEGMENT
A supplement to PIE Magazine issue 04 www.piemagazine.org
Ophthalmic Heroes, Never Fear
Super Vision is Here!
POSTERIOR SEGMENT
Super Vision, a superhero (center), stands next to PIE Person (right), hero of the posterior segment, and Evil Eye (left), an ocular villain. Read more about PIE person and Evil Eye in PIE Magazine issue 04.
Ophthalmic Heroes, Never Fear
Super Vision A new digital revolution has just arrived to redefine visualization in the posterior segment
Visualization is everything when performing vitreoretinal surgeries. Without it, it’s like a superhero without any superpowers.
F
or decades, a surgeon’s only tool for intraocular visualization were analog microscopes. And while they have excellent optics, lighting and depth-of-field – which allow vitreoretinal surgeons to remedy a wide range of surgical conditions – these conventional
ocular devices are restrained by several limitations (including field-of-view, color, contrast, sharpness, excess light exposure to the patient and possible surgeon fatigue). Clearly, new-andimproved instrumentation was needed to reduce those drawbacks, and to allow ophthalmologists to “see” better. Fortunately, with technological breakthroughs in ophthalmic instrumentation, an entirely new digitally-enhanced landscape is opening up for surgeons. Alcon,
the global leader in eye care, has developed a platform for digitallyassisted vitreoretinal surgery that provides a three-dimensional (3D) view of the back of the eye with higher resolution, image depth-of-focus, clarity and color contrast. Ophthalmic heroes, meet your new super power – and the latest tool for vanquishing disease in the posterior segment – the NGENUITY 3D Visualization System. This system is revolutionizing the way surgeons operate in their theaters
On High Magnification
Marco Mura, MD, Chairman of the Retina Division at the King Khaled Eye Specialist Hospital, in Riyadh, Saudi Arabia and Associate Professor at Johns Hopkins University, USA (a.k.a. The Visualization Vindicator)
n is Here! and is transforming the surgical experience. By enhancing visualization and depth-of-field, providing better ergonomics for surgeons and even changing educational practices, this system could ultimately lead to improved outcomes for patients. With a wide range of benefits, including increased depth-of-focus, high dynamic range (HDR) imaging, and reduced light exposure levels (that may help minimize light toxicity),
the NGENUITY 3D Visualization System is redefining the surgical view in operating theaters – and allowing ophthalmologists to view the posterior segment more clearly than ever before. (Say hello to “super vision.”) In this supplement, renowned surgeons (and posterior segment superheroes) who have embraced the NGENUITY 3D Visualization system discuss its many advantages.
Dr. Mura explains that the NGENUITY 3D Visualization System provides improved visualization at high magnification compared to analog microscopy. It provides 26% to 48% greater magnification, delivers up to five times better depth-of-field and produces 11% to 42% finer depth resolution. “Everybody wants to have super vision when they are performing retinal surgery and NGENUITY is bringing us closer to that. NGENUITY offers not only a greater depth resolution, but also a much higher magnification, which improves these delicate surgeries.” The 3D camera systems mean that all depths, from foreground to background, are simultaneously in focus. “The depth of field is so great that you don’t need to refocus continuously during the surgical procedure,” explained Dr. Mura. “And this is where NGENUITY becomes really important: magnification of the macula. You can see it very clearly and much better than you would with a normal analogic microscope. The quality of detail is so great. It improves the surgery, and it hopefully improves the outcome for the patient too.” For Dr. Mura, he finds that since he switched to 3D, it is hard to go back to analog. “I like to have full control of the surgery, and I don’t have any assistants to help me. Very rarely, if I have to use an assistant, it is usually my fellow and I like them to see what’s going on,” he shared. “I find it easier if they can see exactly what I am seeing on the screen. This is a game changer. Once you work with the system and you go back to the optical microscope, you will know it’s not the same. You really miss the high magnification which the NGENUITY system provides.”
POSTERIOR SEGMENT
Like with any new device – or with any superpower for that matter – there is always a learning curve. Dr. Mura said surgeons may feel uncertain in the beginning but encouraged them not to shy away from using the technology. “My advice is to mount it and keep it there from the beginning. After a week or two, you won’t want to leave it. I see it with fellows – they adopt it immediately. We have a large number of fellows and they really love to use the machine. That, to me, is a sign that the technology works,” Dr. Mura concluded.
On Alcon’s ULTRAVIT and Other Innovations
On using the NGENUITY 3D Visualization System for Teaching
Alcon has also introduced the Advanced ULTRAVIT Beveled High Speed Vitrectomy Probe, designed to help surgeons deliver a higher level of precision and efficiency during retina surgery. The bevel tip design brings the cutting port in closer proximity to the retina, allowing the surgeon to access cutting planes that may not be available with a standard flat tip probe. It operates at an ultra-high speed of 10,000 cpm. Dr. Mura noted that this increased speed helps reduce traction that can cause iatrogenic tears and postoperative complications. This results in fewer iatrogenic breaks than spring-driven probes. ULTRAVIT also features a Dual Pneumatic Drive that contributes to reduce vitreoretinal traction and more efficient vitreous removal. Although traction reaches the vitreous base regardless, there is less traction at higher cut rates and smaller gauges. The goal is to reduce this pulsatile vitreoretinal traction. This dual-pneumatic drive technology, in conjunction with CONSTELLATION duty cycle control, helps surgeons as they perform a wide range of maneuvers to address multiple pathologies.
For Associate Professor Ian Yeo, who recently had the NGENUITY system installed at the Singapore National Eye Centre (SNEC), the transition from conventional optical biometers to NGENUITY has not only been easy, but also practical for teaching purposes. “It is actually quite simple to see both the central and the peripheral vitreous using the NGENUITY 3D Visualization System and the view is quite good. It is really useful when our fellows are operating – it is a lot safer because you have more control and you can tell them where they’re going inside the eye.” Meanwhile, for the other members of his surgical team, it has proven to be an entirely enjoyable and immersive experience to be able to use the 3D system. “It’s quite fun to use, the whole theater gets excited wearing 3D glasses. Everyone feels like they are operating too,” shared Prof. Yeo. “Normally for the vitreoretinal surgeries, only the surgeon and the assistant get to have a view of what is really happening. Now the entire theater gets involved in the surgery.” “It also helps keep everyone alert in the operating theater,” added Prof. Yeo.“In the past, I think most of us who watched vitreoretinal surgery fell
Ian Yeo, MD, Head of the Medical Retina Department at the Singapore National Eye Centre (SNEC) in Singapore (a.k.a. The Professor)
The Alcon CONSTELLATION Vision System
asleep because we couldn’t actually see what the surgeon was doing. But now with the new system, we can see in 3D and watch how different surgeons approach the surgery. That is one of the major advantages for our residents and fellows,” he said. “It is a very new technology. But it is something that will probably be adopted by everyone in the future,” continued Prof Yeo. “It changes everything – it’s a quantum leap in the visualization of something that was previously limited to a very small area. The entire team can now see a much clearer 3D view, which then allows for better patient management and clearer understanding by the team. For education, as a tertiary center, this is very useful in teaching our residents and fellows.” “In retinal surgery, visualization is everything. Most of our learning surgeons struggle with the view. With this 3D view, we can show them how to do it. Previously, they were sitting as an assistant, so they only saw things from the side. Now everyone sees the same thing – everyone sees the surgeon’s view,” elaborated Prof. Yeo. “It’s like learning to drive a car, while sitting in the driver’s seat, rather than in the back seat. And with the new viewing system you have enhanced depth-of-view, wider visualization, and you have filters to improve the clarity of structures within the eye. In other words, it’s a totally different view. What you see is what you get. If you like to play 3D computer games, this is as real as it gets,” he said. As for how long it takes to learn to operate with the 3D viewing system, Prof. Yeo says that there isn’t a big learning curve. “The advantages seem to outweigh the cost, as well as any inconvenience of setting it up. It’s still a work in progress and they [Alcon] are still developing the system. I think once it’s fully developed it will be as revolutionary as when we moved from extracapsular to phacoemulsification. It is a game-changer in vitreoretinal surgery.”
Kazuaki Kadonosono, MD, Professor and Chair, Yokohama City University in Japan (a.k.a. The Optical Imager)
On Depth of Field With NGENUITY’s 4K organic lightemitting diode (OLED), medical-grade 55-inch display providing 4K resolution, surgeons get to experience precise, saturated colors. The system delivers up to five times more depth-of-field than with microscopes. “With NGENUITY, when the magnification increases, the denser images increase proportionately. According to recent research, NGENUITY produces 42% finer depths resolution,” said Prof. Kadonosono. In his experience with the NGENUITY 3D Visualization System while performing surgery, he says that NGENUITY allows surgeons to see better with depth-of-images. Because 3D camera systems provide digital imagery, surgeons have the power to adjust color to their advantage. In addition, the NGENUITY 3D visualization system utilizes image processing technology to optimize 3D HDR surgical images in real-time, boosting the intensity of the image which improves contrast, sharpness and color. Surgeons are able to see very dim or fine colors and details more clearly during surgical tasks. Prof. Kadonosono said: “Digital images include contrast, brightness, saturation and gamma hue – and hue is a very important factor in creating sophisticated images. Images with changing hue give us a much clearer picture. I can peel the ILM much more clearly than expected.”
He explained an example of a surgery where he injected tissue plasminogen activator (TPA) into a patient’s central retinal vein. “The color change shows very clear evidence of a successful injection into the central retinal vein. The 3D system in NGENUITY allows us to perform a delicate procedure like cannulation because we are able to get a better feel and sense of depth with images from NGENUITY. This can reduce complications like vitreous hemorrhage at the end of the surgery,” explained Prof. Kadonosono. He also stated that there is a short learning curve with the system and that it wasn’t difficult. “Before I started using the NGENUITY system in my operating theater, I was worried about whether it would take many months to get used to NGENUITY, but actually it was very easy to become familiar with it. One of my fellows will not use any other system except the NGENUITY system. It also takes less time to do surgery with NGENUITY,” shared Prof. Kadonosono. Surgery-induced phototoxicity is sometimes a concern for surgeons and patients because of its potentially significant adverse effects on visual acuity. NGENUITY’s digital technology features very high light sensitivity, which allows surgery to be conducted at photon streams five to 10 times lower than those typically employed with a standard optical microscope.
POSTERIOR SEGMENT
Dr. Manish Nagpal, Senior Consultant, Retina & Vitreous Services, Retina Foundation & Eye Research Centre, Ahmedabad, Gujarat, India (a.k.a. “The One-Screen Wonder”)
NGENUITY’s Digital Illumination Modulation (D.I.M.) helps facilitate operating at lower illumination levels, which may help surgeons visualize anatomical structures, traction, vitreous, and tissue layers, among others. Surgeons may also be able to decrease dye concentrations when staining tissue layers. “With the system, I can peel the internal limiting membrane (ILM) more comfortably and less invasively. In addition, traction may cause slight damage to the retina, so a reduction in traction may result in better visual acuity after surgery,” shared Prof. Kadonosono. The ability of all the team members in the operating room to see the same view as the surgeon via the big screen is also an important advantage for Prof. Kadonosono. “The advantages of NGENUITY include less phototoxicity and digital staining, and also teaching skills for all participants inside the operating theater,” he said. Despite a few disadvantages to the NGENUITY, such as having to allocate more space to place the 55-inch monitor, and the cost of the system, he said that the system is well worth it. “I like all the aspects and advantages of NGENUITY and I recommend it. The advantages outweigh the small number of disadvantages,” he concluded.
On data parameters, ergonomics and customization with DataFusion Previously, Dr. Manish Nagpal has used the classic NGENUITY for surgery alongside the Constellation monitor for data parameters. “In traditional NGENUITY, all the vitrectomy parameters – the cutting, suction, lighting, diathermy, IOP pressures, air fluid, etc. – they all are on the Constellation monitor, he said. “So, for surgery, we look at the NGENUITY monitor, but for all the data parameters, we look at Constellation screen.” The use of two screens means that the surgeon has to relay data parameters to an assistant and momentarily look over to the Constellation screen during surgery to verify. In Dr. Nagpal’s operating theater, the NGENUITY system is slightly toward his right, about 1.5m away, while Constellation is 90 degrees to the right. “If I look at Constellation parameters, I have to turn my head right – and it’s an effort. You have to momentarily change your view from the surgery to the parameters.” To combat this, Alcon has recently released a posterior-segment imaging super-instrument that will combine the surgery and parameters into one screen: DataFusion. This first-of-itskind technology in retina surgery provides surgeons with a “digital cockpit” of sorts, where they can
view all surgical parameters and the surgery on the same screen. Primary data (like that formerly on the Dr. Nagpal’s Constellation screen) will now be displayed on NGENUITY – this hardware and software upgrade brings all the Alcon Constellation parameters right into the 3D display. Dr. Nagpal says this overlay (with DataFusion) will enhance ergonomics as surgeons will not have to look away from the surgical screen to check or adjust parameters. This will also reduce the possibility of communication or human error, as the surgeon can easily check parameters with a glance. “Simply speaking, with DataFusion, the ergonomics of not having to look at two screens is great,” he said. “You only need to look at one screen with DataFusion.” He also notes that with DataFusion, there is less chance of error. Dr. Nagpal relays an example: “Say there is a clinical assistant handling Constellation, and the surgeon is looking at NGENUITY and operating. If we tell the assistant we need an infusion of 13, we need to move our head to verify that. This is where there is a slight chance of error . . . or maybe the assistant has done something accidently, like infusing 30 instead of 13 – it happens. Or maybe the vacuum could be off due to communication errors. These are practical things that happen in the operating room – but with NGENUITY we see it right away.”
But won’t all the data parameters crowd the surgical screen? Not, so. DataFusion’s presentation is elegant, uncluttered and in the periphery to minimize distraction. Even better – it’s customizable. The opacity of the fonts and progress bars can be adjusted and programmed to suit the surgeon’s preference. “Some people would not like their data to be covering too much of the surgical screen,” said Dr. Nagpal. “With a standard overlay, sometimes the data can be cluttered – and either the surgeon likes it or doesn’t. But DataFusion can be customized [to show more or less of the parameters].”
Super Vision: The Future is Now Dr. Nagpal believes that NGENUITY 3D Visualization System will change the way ophthalmologists operate. With this system, surgeons have much higher magnifications and can make digital enhancements that were not possible before – making NGENUITY a true digital platform for Digitally Assisted Surgery (DAS). “The future capabilities are promising because of NGENUITY and
continuous digital improvements,” he explained. “The optical microscope has limitations.” In addition, recent enhancements to the display rendering technology have eliminated perceptible latency in newer NGENUITY shipments (previous versions are upgradeable). “The latency has decreased from 90 to 70 milliseconds,” said Dr. Nagpal. “For example, when I am operating, I’m moving something from X to Y on a screen and I’m seeing that much delay – this change in NGENUITY reduces that lag time.” He says that this will make a difference when a surgeon is outside the eye and putting canals inside. “That’s when you could over- or undershoot by mistake – the latency is not something that usually gets in the way otherwise.”
He says that this new “super vision” will require surgeons to make some changes. “Before, we worked with a microscope, now we are looking at a screen and not limited to an eye piece. We have the ability to magnify, use filters and use a picture-in-picture interface.” Super vision, indeed. “Because the technology is new, expect to see more clinical results with more experience,” stated Dr. Nagpal. “We have to experience this whole technological shift in larger numbers, and there is a lot of scope. Right now, we are only seeing a very superficial enhancement-based aspect.” “The more that people use it, the more they will find out,” he added. “People will find that with higher magnification you can do a fine peel on a macular hole because you can really get close, whereas with microscopes, you keep magnifying it, but lose quality.” Dr. Nagpal has been using Constellation since 2009, and NGENUITY for one month (at press time) – which has transformed his experience with Constellation. India is one of the first markets to receive DataFusion and he expects to have it very soon.
Audience members watched an NGENUITY video in 3D at APAO 2018 Hong Kong
POSTERIOR SEGMENT
The NGENUITY 3D Visualization System: In Summary The NGENUITY 3D Visualization System allows retinal surgeons to operate using a high-definition 3D screen, instead of bending their necks to look through the eye-piece of a microscope. It works through a small camera box, which is attached to the microscope where the oculars are usually placed, and then displays the view on a 55-inch OLED screen. The surgeon wears polarized glasses, sits back in the chair, and operates looking heads-up at the screen. Traditional vitrectomy surgeries range from 30 minutes to more than three hours. Advantages of the system include better posture for surgeons, leading to less neck and back pain, which may also reduce fatigue. The NGENUITY 3D Visualization
Alcon’s NGENUITY 3D Visualization System, a platform for Digitally Assisted Vitreoretinal Surgery (DAVS)
System is comprised of several elements. It features a HDR camera that provides excellent resolution, image depth, clarity and color contrast. The 3D view gives the surgeon depth perception that was not previously available on standard television monitors, which are often used in the operation theater. Surgeons may also increase magnification while maintaining a wide field-of-view, as well as use digital filters that highlight ocular structures and tissue layers to customize his or her view during each procedure, which is imperative to visualize the back of the eye. Aimed at minimizing light exposure to the patient’s eye, the NGENUITY 3D Visualization System makes it easier to conduct surgeries using lower light levels, which is beneficial to the patient. The system is designed to facilitate collaboration and teaching in the operating room. Offering an
immersive panoramic surgical view, the NGENUITY 3D Visualization System allows the operating team to see exactly what the surgeon is seeing in real-time, a valuable advantage to this field. NGENUITY redefines how surgeons see, filling their view with depth, dimension and detail. And when surgeons can see more, they can can do more. The NGENUITY 3D Visualization System was developed in collaboration with TrueVision 3D Surgical, a California-based leader in digital 3D visualization and guidance for microsurgery. It consists of a 3D stereoscopic, high-definition digital video camera and workstation to provide magnified stereoscopic images of objects during micro-surgery. It acts as an adjunct to the surgical microscope during surgery displaying real-time images or images from recordings.