Lindstrom's Perspective

For surgery, transition to digital imaging is imminent

I was first introduced to ophthalmology as a second-year medical student at the University of Minnesota in 1970. During my 6-week rotation I was exposed to the cornea/cataract/glaucoma, retina, pediatric ophthalmology/plastic surgery and neuro-ophthalmology subspecialists at the university medical center. At that time, only patients referred by an ophthalmologist were accepted by the university physicians. This made it a tertiary referral center in the truest sense. During medical school I also took the time to visit several private practice ophthalmologists and gain insight into the private sector of ophthalmology. I fell in love with ophthalmology after those rotations and a later opportunity to work in the research laboratory and clinic of Donald J. Doughman, MD, a newly minted corneal/anterior segment specialist from Harvard. As amazing as it may seem to the younger ophthalmologist of today, patients at that time were admitted to the hospital for 4 to 7 days after cataract surgery, and after corneal transplants, mostly penetrating keratoplasty, for 7 to 10 days.

The subspecialists at the University of Minnesota did their cataract and corneal surgery using a Zeiss Opmi 1 operating microscope. The surgery performed was intracapsular cataract extraction, and few IOLs were implanted. It was considered quite advanced at the time, now nearly 50 years ago, to use an operating microscope for cataract surgery or, for that matter, any other ophthalmic surgery. Most of the private practice ophthalmologists I visited, who also operated in a general hospital environment, used magnifying loupes to perform their cataract surgery. Silk and chromic sutures, usually 6-0 or 7-0, were utilized most frequently to close the large cataract incisions. At the university, 10-0 nylon had been adopted by the microsurgeons using the Zeiss Opmi 1 microscope, and we had these microscopes at all four of the teaching hospitals, so the Minnesota residents were trained to do their cataract surgery under an operating microscope. But most of the community ophthalmologists were at the time unconvinced that the microsurgical approach was superior to loupes, which allowed more flexibility in moving to different positions while doing the procedure.

We are all aware that for the past 40 years, cataract surgery under an operating microscope has been adopted by all ophthalmic anterior segment surgeons in advanced countries. The reason is superior visualization of the tissues being operated upon. Microscopes have continued to advance, and the Zeiss Lumera series operating microscopes being utilized in our ambulatory surgery centers at Minnesota Eye Consultants allow fantastic visualization and a wide range of magnification. The next advance, real-time intraoperative OCT, is being pioneered by several companies including Zeiss, with significant potential benefits to the corneal surgeon doing lamellar keratoplasty and the retinal surgeon peeling an epiretinal membrane. We also have operating microscope adjuncts such as intraoperative aberrometry, surgical keratoscopes and toric IOL alignment adjuncts such as Verion (Alcon) or Callisto (Zeiss) that offer meaningful benefit to surgeons and patients.

What could be better? Some think a transition to 2-D or 3-D digital imagery on a large screen. Some pioneering anterior segment and vitreoretinal ophthalmic surgeons believe in the near future we will abandon the operating microscope in favor of similar technology to that now favored by many of our neurosurgeon, urology, orthopedic and general surgeon colleagues who are using large digitized 2-D or 3-D images on a screen to guide their surgery, often in combination with robotics. Potential advantages include increased magnification, the ability to sit comfortably and easily change positions when beneficial without being tied to an operating microscope, and the use of adjuncts such as robotics. In addition, overlay guidance can be utilized to enhance surgical performance such as capsulorrhexis size and toric IOL axis alignment, and direct visualization of OCT images can be alternatively displayed and even overlaid on the digital image. Color can be amplified and specific areas enhanced in detail.

I have only worked with the TrueVision Ngenuity 3-D system in the laboratory setting, but I am intrigued by the possibilities. At a minimum, it is an amazing tool for teaching and training surgeons in new surgical maneuvers. As another beneficial side effect, it may mitigate the epidemic of microscope-induced neck and back pathology common in ophthalmic surgeons caused by decades of poor posture while looking through slit lamps and operating microscopes. I can imagine the next generation of surgeons being trained on this digital imaging technology and foresee a future in which the operating microscope is seldom used, except perhaps to capture an image to be displayed digitally. The oculars on the microscope will no longer be needed.

The only constant in our field is change, and a transition to digital imaging to guide our surgery vs. the classical operating microscope in the next decade is more than science fiction but moving fast toward reality. We 70-year-old surgeons will likely finish our careers looking through an operating microscope as we perform our procedures, but those ophthalmologists 10 to 40 years younger are likely on their way to the digital age even while in the operating room.

Disclosure: Lindstrom reports he has a financial interest in and/or consults for TrueVision, Alcon and Zeiss.

I was first introduced to ophthalmology as a second-year medical student at the University of Minnesota in 1970. During my 6-week rotation I was exposed to the cornea/cataract/glaucoma, retina, pediatric ophthalmology/plastic surgery and neuro-ophthalmology subspecialists at the university medical center. At that time, only patients referred by an ophthalmologist were accepted by the university physicians. This made it a tertiary referral center in the truest sense. During medical school I also took the time to visit several private practice ophthalmologists and gain insight into the private sector of ophthalmology. I fell in love with ophthalmology after those rotations and a later opportunity to work in the research laboratory and clinic of Donald J. Doughman, MD, a newly minted corneal/anterior segment specialist from Harvard. As amazing as it may seem to the younger ophthalmologist of today, patients at that time were admitted to the hospital for 4 to 7 days after cataract surgery, and after corneal transplants, mostly penetrating keratoplasty, for 7 to 10 days.

The subspecialists at the University of Minnesota did their cataract and corneal surgery using a Zeiss Opmi 1 operating microscope. The surgery performed was intracapsular cataract extraction, and few IOLs were implanted. It was considered quite advanced at the time, now nearly 50 years ago, to use an operating microscope for cataract surgery or, for that matter, any other ophthalmic surgery. Most of the private practice ophthalmologists I visited, who also operated in a general hospital environment, used magnifying loupes to perform their cataract surgery. Silk and chromic sutures, usually 6-0 or 7-0, were utilized most frequently to close the large cataract incisions. At the university, 10-0 nylon had been adopted by the microsurgeons using the Zeiss Opmi 1 microscope, and we had these microscopes at all four of the teaching hospitals, so the Minnesota residents were trained to do their cataract surgery under an operating microscope. But most of the community ophthalmologists were at the time unconvinced that the microsurgical approach was superior to loupes, which allowed more flexibility in moving to different positions while doing the procedure.

We are all aware that for the past 40 years, cataract surgery under an operating microscope has been adopted by all ophthalmic anterior segment surgeons in advanced countries. The reason is superior visualization of the tissues being operated upon. Microscopes have continued to advance, and the Zeiss Lumera series operating microscopes being utilized in our ambulatory surgery centers at Minnesota Eye Consultants allow fantastic visualization and a wide range of magnification. The next advance, real-time intraoperative OCT, is being pioneered by several companies including Zeiss, with significant potential benefits to the corneal surgeon doing lamellar keratoplasty and the retinal surgeon peeling an epiretinal membrane. We also have operating microscope adjuncts such as intraoperative aberrometry, surgical keratoscopes and toric IOL alignment adjuncts such as Verion (Alcon) or Callisto (Zeiss) that offer meaningful benefit to surgeons and patients.

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What could be better? Some think a transition to 2-D or 3-D digital imagery on a large screen. Some pioneering anterior segment and vitreoretinal ophthalmic surgeons believe in the near future we will abandon the operating microscope in favor of similar technology to that now favored by many of our neurosurgeon, urology, orthopedic and general surgeon colleagues who are using large digitized 2-D or 3-D images on a screen to guide their surgery, often in combination with robotics. Potential advantages include increased magnification, the ability to sit comfortably and easily change positions when beneficial without being tied to an operating microscope, and the use of adjuncts such as robotics. In addition, overlay guidance can be utilized to enhance surgical performance such as capsulorrhexis size and toric IOL axis alignment, and direct visualization of OCT images can be alternatively displayed and even overlaid on the digital image. Color can be amplified and specific areas enhanced in detail.

I have only worked with the TrueVision Ngenuity 3-D system in the laboratory setting, but I am intrigued by the possibilities. At a minimum, it is an amazing tool for teaching and training surgeons in new surgical maneuvers. As another beneficial side effect, it may mitigate the epidemic of microscope-induced neck and back pathology common in ophthalmic surgeons caused by decades of poor posture while looking through slit lamps and operating microscopes. I can imagine the next generation of surgeons being trained on this digital imaging technology and foresee a future in which the operating microscope is seldom used, except perhaps to capture an image to be displayed digitally. The oculars on the microscope will no longer be needed.

The only constant in our field is change, and a transition to digital imaging to guide our surgery vs. the classical operating microscope in the next decade is more than science fiction but moving fast toward reality. We 70-year-old surgeons will likely finish our careers looking through an operating microscope as we perform our procedures, but those ophthalmologists 10 to 40 years younger are likely on their way to the digital age even while in the operating room.

Disclosure: Lindstrom reports he has a financial interest in and/or consults for TrueVision, Alcon and Zeiss.