Three-dimensional, high-definition visualization is revolutionizing vitreoretinal surgery.

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LOOKING INTO THE FUTURE …

TODAY

Series No. 1

It’s time to rewrite the rules of vitreoretinal surgery.

• The ULTRAVIT® 7500cpm probe provides the benefi t of faster cutting and smaller vitreous biteswithout fl uidic compromise.1

• Trust in integrated and stable IOP compensation2, 3

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vitreoretinal surgery.

smaller vitreous bites

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Caution: Federal law restricts this device to sale by, or on the order of, a physician. Indications for Use: The CONSTELLATION® Vision System is an ophthalmic microsurgical system that is indicated for both anterior segment (i.e., phacoemulsi� cation and removal of cataracts) and posterior segment (i.e., vitreoretinal) ophthalmic surgery. The ULTRAVIT® Vitrectomy Probe is indicated for vitreous cutting and aspira-tion, membrane cutting and aspiration, dissection of tissue and lens removal. The valved entry system is indicated for scleral incision, cannulae for posterior instrument access and venting of valved cannulae. The infusion cannula is indicated for posterior segment infusion of liquid or gas. Warnings and Precautions: The infusion cannula is contraindicated for use of oil infusion. The disposables used in conjunction with ALCON® instrument products constitute a complete surgical system. Use of disposables and handpieces other than those manufactured by Alcon may a� ect system performance and create potential hazards. Attach only ALCON® supplied consumables to console and cassette luer � ttings. Do not connect consumables to the patient’s intravenous connections. Mismatch of consumable components and use of settings not speci� cally adjusted for a particular combination of consumable components may create a patient hazard. Vitreous traction has been known to create retinal tears and retinal detachments. The closed loop system of the CONSTELLATION® Vision System that adjusts IOP cannot replace the standard of care in judging IOP intraoperatively. If the surgeon believes that the IOP is not responding to the system settings and is dangerously high or low, this may represent a system failure. Note: To ensure proper IOP Compensation calibration, place infusion tubing and infusion cannula on a sterile draped tray at mid-cassette level during the priming cycle. Leaking sclerotomy may lead to post operative hypotony. Attention: Please refer to the CONSTELLATION® Vision System Operators Manual for a complete listing of indications, warnings, and precautions.

1. Abulon, et al. Porcine Vitreous Flow Behavior During High Speed Vitrectomy up to 7500 Cuts Per Minute. ARVO Poster, 2012. 2. Riemann C, et al. Prevention of intraoperative hypotony during vitreoretinal surgery: an instrument comparison. ASRS Poster Presentation, 2010.* 3. Buboltz, DC. New method for evaluating fl ow rates and intraocular pressures during simulated vitreoretinal surgeries. ARVO Congress Poster Presentations, 2010. Fort Lauderdale, FL.* 4. Nagpal M, et al. Comparison of clinical outcomes and wound dynamics of sclerotomy ports of 20, 25, and 23 gauge vitrectomy. Retina. 2009;29(2):225-231. 5. Davison JA, Cumulative tip travel and implied follow ability of longitudinal and torsional phacoemulsifi cation J Cataract Refract Surg 2008; 34:986–990 6. Alcon data on fi le 954-0000-004. 7. Fernández de Castro, L. E. et al. (2010). Bead-fl ow pattern: Quantization of fl uid movement during torsional and longitudinal phacoemulsifi cation. J Cataract Refract Surg 36(6): 1018-1023.*Based on bench lab testing.

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LOOKING INTOTHE FUTURE …TODAY

Three-dimensional, high-definition visualization is revolutionizing vitreoretinal surgery.

Looking Into the Future … Today

Thomas M. Aaberg Jr., MD

Thomas M. Aaberg Jr., MD, is founder

and president of Retina Specialists of

Michigan in Grand Rapids. Dr. Aaberg is

a consultant to Alcon and TrueVision.

He may be reached at (616) 954 2020;

thomasaaberg@comcast.net.

Marco Mura, MD

Marco Mura, MD, is professor of ophthal-

mology at the Wilmer Eye Institute, Johns

Hopkins University School of Medicine in

Baltimore, and chief of the retina division

at the King Khaled Eye Specialist Hospital

in Riyadh, Saudi Arabia. Dr. Mura is a con-

sultant to Alcon. He may be reached at

mmura1@jhmi.edu; drmmura@yahoo.com.

Christopher D. Riemann, MD

Christopher D. Riemann, MD, is in private

practice at Cincinnati Eye Institute and

is the vitreoretinal fellowship director at

the University of Cincinnati. Dr. Riemann

is a consultant to Alcon, TrueVision, and

Haag-Streit Surgical, and he has stock

options in TrueVision. He may be reached

at criemann@cincinnatieye.com.

4 INSERT TO RETINA TODAY | JULY/AUGUST 2016

LOOKING INTOTHE FUTURE …TODAY

Is the entrance to your operating room a portal to the past? When it comes to visualizing your surgical field, are you taking a step back in time? This is entirely likely, according to several retina specialists who have seen the future.

“Today, we have amazing imaging modalities in our clinics—OCTs, fluorescein angiograms, ultrasounds—but as soon as we enter our operating rooms, we leave it all behind, as we position ourselves at a microscope that uses circa-1960 technology,” says Thomas M. Aaberg Jr., MD, founder and president of Retina Specialists of Michigan in Grand Rapids. “Other than the sleek-ness of the design and the addition of some peripheral features, the surgical microscope has changed very little.”

What distinguishes old technology from advanced technol-ogy in imaging and visualization? In a word, digitization, says Christopher D. Riemann, MD, who is in private practice at Cincinnati Eye Institute and vitreoretinal fellowship director at the University of Cincinnati.

“From an optical perspective, the microscopes of today are only incrementally better than they were a half century ago, while everything else in the OR, from our vitrectomy machines to the music we listen to, has been digitized,” Dr. Riemann says. “The microscope has lagged because digitizing an image for microsurgery requires the highest quality video at dynamic ranges and resolutions that are comparable to or better than what we see through the microscope. That technology has only recently become available.”

Dr. Riemann and Dr. Aaberg, who each hold degrees in biomedical engineering, are early adopters of digitally assisted vitreoretinal surgery, using a new 3D, high-definition, surgical visualization platform called Ngenuity (Alcon), which converts an optical microscope into a digital imaging system. Both surgeons have provided input into the design and functional-ity of the system for retina surgery. In fact, Dr. Riemann has been advising TrueVision 3D Surgical, the original creators of this technology, for nearly a decade. By 2008, he was already performing this type of vitreoretinal surgery on select cases using an early version of this system, and in 2010, he presented the first retina cases using this technology at the American Academy of Ophthalmology Annual Meeting.1

“Back then, it was a labor of love, but there have been huge improvements in the past 7 years,” Dr. Riemann says. “There is no surgery that I know how to do that I would not be comfortable doing with this system. In fact, I would prefer doing all of my sur-geries with this new digital microscopy system. It has the very best high dynamic range, high-resolution 3D camera on the market. It is an exquisitely powerful camera with fantastic latency.”

Dr. Riemann notes the lure of new technology is strong among retina specialists, but to replace an iconic piece of equipment, such as the surgical microscope, surgeons require unequivocal, tangible benefits. “Those benefits exist, right now, today,” he says.

Perhaps the most obvious is the improved ergonomics with digital vitreoretinal surgery.

ERGONOMIC ADVANTAGEOphthalmologists in general and retina surgeons in particu-

lar are at risk for work-related musculoskeletal injuries, owing to the ergonomic hazards intrinsic to practice, such as main-taining awkward or static postures at the slit lamp and the surgical microscope.

“During vitreoretinal surgery, we are locked to the scope for the duration of the operation, holding our heads in a nonphysi-ological position, craning our shoulders forward, and extending our necks, which cause musculoskeletal fatigue and wears down the joints,” Dr. Riemann says.

In a survey of US ophthalmologists, 51.8% reported neck, upper extremity, or lower back symptoms.2 In a similar survey of US retina surgeons, 55.4% of respondents reported both back and neck pain; 21% reported back pain; and 8.3% reported neck pain.3 Only 15% were symptom-free. In a survey of eye care pro-fessionals in Saudi Arabia, 70% of respondents reported neck and back pain.4

These statistics come as no surprise to Marco Mura, MD, professor of ophthalmology at the Wilmer Eye Institute, Johns Hopkins University School of Medicine in Baltimore, Maryland, and chief of the retina division at the King Khaled Eye Specialist Hospital in Riyadh, Saudi Arabia. “As a high-volume surgeon, I, too, experience neck problems after a long surgery day using the optical microscope,” Dr. Mura says. “With this new ocular-free system, I operate in an ergonomically neutral position while viewing a magnified image on a large monitor. I can achieve the same results as I do when I use the surgical microscope but without neck and shoulder pain.”

Dr. Riemann predicts his adoption of this 3D visualization sys-tem will have a profound and positive effect on his health and career. “I am a healthy 48-year-old, and I do not have cervical spine problems, but I am a busy surgeon,” he says. “I operate two full days a week, every week. If I have been sitting at the microscope

Figure 1. After operating a full day at the surgical microscope,

Dr. Riemann often experiences neck and shoulder discomfort.

Photo courtesy of Christopher D. Riemann, M

D.

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LOOKING INTOTHE FUTURE …TODAY

all day (Figure 1), I am still a happy guy (after all, retina surgery is awesome!!), but I am cracking my neck and rubbing my shoulders because they hurt. At the end of a surgery day using the Ngenuity system (Figure 2), I come home skipping, laughing, and whistling. I am a happy camper. I am absolutely convinced that digital vitreo-retinal surgery will extend my career as a surgeon by 10 years.”

Although a significant benefit to the surgeon’s well-being, ergonomics is just one of the advancements the new 3D system brings to the OR.

DIGITALLY ENHANCED VISUALIZATIONProper illumination is essential for visualizing the dark, micro-

environment at the back of the eye during vitreoretinal surgery, but despite the availability of various types of endoillumination designed for this purpose, light toxicity remains a concern.

“Phototoxicity is a real thing,” Dr. Riemann says. “It does not happen frequently, but when it happens, it can have a signifi-cant adverse effect on visual acuity.5 With this new technology, I can operate with much lower light levels than when I operate optically. If I am performing a 27+ gauge vitrectomy through the microscope using the Constellation Vision System (Alcon), for example, my light pipe is usually set at 35%. For macular work using the new 3D system, I set it at 5%. That is one-seventh the photons exiting the light pipe and one-seventh the light exposure to the retina—which is huge. If I can complete the same procedure with less light, why would I choose to oper-ate with higher light levels?”

Researchers from Wills Eye Hospital in Philadelphia agreed with this notion and presented data from a pilot study in which they correlated endoillumination levels used during ocular-free vitreoretinal surgery to subjective digital image quality and 3D display luminous emmitance.6 They concluded that a 3D digi-tal platform with real-time digital processing and automated

brightness control may allow for reduced intraoperative endoillumination levels and a theoretically reduced risk of reti-nal phototoxicity during vitreoretinal surgery.

Another major advantage of the new technology is that sur-geons can digitally enhance tissue planes by adjusting light bal-ance and contrast and applying digital filters, potentially reduc-ing the concentration of vital dye needed during surgery.

“This system brings a lot of value to the retina surgeon,” Dr. Mura says. “Not only can I use less light, but I can also add color digitally instead of using a staining material to see transparent tissue. For example, the vitreous can be difficult to identify, par-ticularly in young patients, so I amplify the blue gain, which adds a bluish tint to aid in visualization. When peeling the internal limiting membrane, I digitally apply a red-free filter (Figure 3)”.

Minimizing or potentially eliminating vital dyes from vitreo-retinal surgery is beneficial on two levels, Dr. Mura says. “First, whenever we inject something into the eye, we are performing an extra maneuver, which has associated risks,” he says. “Second, some of the stains we use to aid in visualization may be toxic to the retina or cause adverse side effects.”7

According to Dr. Aaberg, “Using what I call video chroma-tography to enhance or minimize color pixels enables me to visualize tissue planes as well as or better than I can using the microscope and vital dyes. This makes my surgeries more efficient with less risk of iatrogenic damage to the retina. For my standard cases, I use a 5% illumination setting on the Constellation and if I am using a vital dye, I can then reduce the concentration by 50%. I can discern no difference between what I see using this new 3D system (Figure 4) and what I see using the usual light settings and dye concentrations with the tradi-tional OR microscope.”

Dr. Mura also appreciates the high magnification capability of the monitor, which is now available with an ultra high-definition

Figure 2. The ocular-free system allows Dr. Riemann to

operate in an ergonomically neutral position, avoiding neck

and shoulder discomfort.

Figure 3. The 3D digital platform allows the surgeon to digitally

apply a red-free filter.

Phot

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of Ch

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D. R

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D.Photo courtesy of Thom

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D

6 INSERT TO RETINA TODAY | JULY/AUGUST 2016

LOOKING INTOTHE FUTURE …TODAY

4K 3D display. “The resolution of images on the screen is com-parable to, and in some situations even better than, that of the microscope,” he says. “There is a limit to how much we can mag-nify the surgical field using the optical system. Once we reach that limit, if we try to magnify the field further, we lose resolution. With the digital system, I can enlarge the image even further to see the microstructures of the retina with clarity.”

Another unique feature that this new, ergonomic 3D system brings to the OR is the ability to show diagnostic imaging side-by-side with the live surgical field. “Using a traditional micro-scope, we cannot bring all of that information with us into the OR,” Dr. Aaberg says. “We would have to look away from the oculars to look up at another screen, and any time we glance away from the microscope, we risk making a mistake. With this system, I can view the surgical field on the full screen, or I can reduce that image to two-thirds and divide the remaining viewing area to accommodate a fluorescein angiogram and an OCT imported from my clinic.”

REAL-TIME RESPONSIVENESSWhen discussing any digital technology, particularly related

to ophthalmic surgery, the question of latency often arises. The question has merit, Dr. Aaberg says. “Whenever software enhancements are incorporated into digital technology, pro-cessing times may increase, potentially creating more latency. This is something the engineers continually address as they work on the next generation of innovations.”

Dr. Riemann explains, “The magic number for acceptable latency for primary digital surgical viewing is 100 milliseconds. Many people say, ‘My goodness, that is a tenth of a second. Is that not a really long time?’ but you have to ask a different question. It is not that the microscope has zero latency and the Ngenuity system has 80 milliseconds of latency. The latency of the microscope or the digital visualization system has to be added to the latency of human reaction time, the time that elapses from when you see something to when your hands act on what you have just seen. Depending on how old you are—reaction times for kids are faster than for adults—that is somewhere between 150 and 300 milliseconds. This means the latency of any system must be added to the 300 milliseconds of human reaction time. Therefore, with the microscope, the latency is 300 milliseconds, and with this new technology it is less than 380 milliseconds. The difference between the two is less than 100 milliseconds.

“We also need to remember that retina surgery is slow and deliberate,” Dr. Riemann continues. “With the current iteration of capture, rendering, and display, there is absolutely no clini-cally relevant latency.”

FAST ADAPTATIONIntroducing new technology into the OR generally requires

a period of adaptation, and some surgeons may be concerned

about a long learning curve and its impact on outcomes. In fact, a retrospective analysis of cases performed by a single vitreo-retinal surgeon over a 2-month period found that transition-ing from the traditional surgical microscope to an ocular-free system did not increase surgical times or negatively affect out-comes.8

“The transition from the optical microscope to the digital sys-tem is fast, particularly for the new generation of surgeons,” Dr. Mura says. “I always have my fellows test any new instrumenta-tion. Depending on their reactions and their adaptation times, I decide whether it is feasible for everyone to use. What I have seen with the new 3D visualization system is that they adapt within a matter of hours.”

When discussing adaptation, Dr. Riemann differentiates between “digital natives”—the millennials who never lived in a world without smartphones, video games, and the Internet—and “digital immigrants,” older people who migrated from the analog age to the digital age as young adults. “Digital immi-grants usually become proficient using the system after three to five cases,” he says. “Digital natives, on the other hand, are usual-ly zipping through after their first case. Fellows who are learning surgery are usually proficient with the system within one to two cases. Their surgical ability, not the digital visualization system, becomes the rate-limiting factor.”

INNOVATION NOW AND IN THE FUTUREAs excited as they are about the 3D visualization system

today, these surgeons are already looking toward future advancements in digitally assisted vitreoretinal surgery.

“In the future, we will be able to simultaneously view not only the live surgical field but also other relevant information, such as an ancillary video feed from an endoscope or an intra-operative OCT image,” Dr. Riemann says. “Future innovations may enable us to view active, real-time machine settings, such as vacuum, cut rate, and duty cycle. I envision this system as a multidiscipline information-handling platform, a surgical

Figure 4. Stereo image demonstrating the quality of the surgical

view using the digital 3D system with only 5% illumination and

50% less dye concentration than typically used.

Photo courtesy of Thomas M

. Aaberg Jr., MD

JULY/AUGUST 2016 | INSERT TO RETINA TODAY 7

LOOKING INTOTHE FUTURE …TODAY

cockpit that will give me the information I want, where I want it, when I need it.”

Dr. Aaberg notes that TrueVision initially introduced its visu-alization system to the neurology specialty, and prior to bring-ing it to retina, it was already being used by cataract surgeons. “One of the first applications for the anterior segment was the ability to overlay corneal topography onto the surgical field, enabling the surgeon to precisely orient toric intraocular lenses and astigmatic corrections,” he says. “Imagine if we could proj-ect a fluorescein angiogram directly over the surgical field to guide laser treatment of an area of nonperfusion and have this image register to and track with the live surgical image.

“The next quantum step for us as retina surgeons will not be how we do surgery, but how we view surgery,” Dr. Aaberg continues. “Digital microscopy will give us the opportunity to use all of the forms of retinal imaging that we have grown accustomed to using in our clinics—and probably retinal imag-ing that has not even been invented yet—and to bring them into the OR.”

Dr. Riemann concludes: “This system is revolutionizing retina surgery starting right now, but in 10 years, we will look back and wonder how we ever performed surgery while looking through a microscope. I have no doubt that digitally enhanced visualization of the retinal surgical field will dra-matically improve the efficacy and safety of the entire family of vitreoretinal surgical procedures.” n

1. Riemann CD. Machine Vision and Vitrectomy: Three-dimensional High-definition Video for Surgical Visualization in the Retina OR. Poster presented at: American Academy of Ophthalmology Annual Meeting; October 17, 2010; Chicago, IL.2. Dhimitri KC, McGwin G Jr, McNeal SF, et al. Symptoms of musculoskeletal disorders in ophthalmologists. Am J Ophthalmol. 2005;139:179-181.3. Desai URT, Abdulhak MM, Bhatti R. Occupational Back and Neck Problems in Vitreoretinal Surgeons. Paper presented at: American Society of Retina Specialists Annual Meeting; August 2004; San Diego, CA4. Al-Marwani Al-Juhani M, Khandekar R, Al-Harby M, et al. Neck and upper back pain among eye care professionals. Occup Med (Lond). 2015;65:753-757.5. Youssef PN, Sheibani N, Albert DM. Retinal light toxicity. Eye (Lond). 2011;25:1-14.6. Thornton S, Adam MK, Ho AC, Hsu J. Endoillumination levels and display luminous emittance during three-dimensional heads-up vitreoretinal surgery. Poster presented at: Annual Meeting of the Association for Research in Vision and Ophthalmology; May 4, 2016; Seattle, WA.7. Gandorfer A, Haritoglou C, Kampik A. Toxicity of indocyanine green in vitreoretinal surgery. Dev Ophthalmol. 2008;42:69-81.8. Barakat M. Learning to Use a Stereoscopic Display With Retinal Surgery Does Not Increase Surgical Time or Negatively Affect Outcomes. Poster presented at: 2016 Annual Meeting of the Association for Research in Vision and Ophthalmology; May 4, 2016; Seattle, WA.

ADVANCED TEACHING TOOLDr. Riemann has been teaching 3D vitreoretinal surgery to fellows

for several years. Not only are the fellows upping their game by learn-ing this cutting-edge technology, but both Dr. Riemann and the fel-lows appreciate the learning experience afforded by the heads-up 3D visualization platform.

“Teaching is amazing with this system,” Dr. Riemann says. “I sit 3 to 4 feet behind my fellows when they operate. They know I am there, but I am not in their field of view, which creates a sense of autonomy for them, decreasing their anxiety (Figure).

“My anxiety is less for two reasons,” he continues. “First, I can see exactly what the fellow is seeing. If a fellow is using a scope that has non-coupled zoom, I may question whether my zoom is different from that of the fellow. Second, if the fellow is using the surgical microscope and we need to switch places, I cannot do anything until I adjust the scope to my pupillary distance, which is wider than average, and that takes up to 10 seconds. With this system, the fellow places the instruments in the trough, kicks back, and I come in. The switch is fast and seamless.”

Dr. Mura also reports that the new system is a valuable teaching tool. “Having a large screen that allows everyone in the OR to see the same image is beneficial for teaching purposes,” he says. “Not only can I see what the fellow is doing, but I can also show him or her specific tissue on the screen—where to start peeling a membrane, for example. This is not possible when the fellow is using a traditional microscope. I believe this improves safety during the teaching process and increases the fellow’s confidence.

“The system also facilitates the flow of the procedure,” Dr. Mura says. “The nurse can follow the surgery on the screen and see which instruments will be required. When the whole team is involved in the

surgical process, everyone is more focused.”Dr. Riemann notes the latest generation of the ocular free surgery

has created an environment where he is likely to encourage his fel-lows to tackle more complex surgeries. “Every one of my fellows in the past 3 or 4 years has had the opportunity to do some of this type of surgery,” he says. “But now that we are using next-generation equipment with even more refinements, I am comfortable allow-ing them to do more. The ergonomics make sense. The workflow is good. The system is user friendly. You turn it on, you white-balance the camera, and you are good to go for the day. Our fellows, who are all millennials, sit down and they just do it. It is beautiful.”

Figure. Dr. Riemann supervises fellow Cindy Mi, MD, as she

performs a phaco vitrectomy and membrane peel for a case of

diabetic traction retinal detachment.

Photo courtesy of Christopher D. Riemann, M

D

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