Examining Ophthalmic Surgical Microscopes

The ASC is a choice setting for today’s new technologies. Find out why.

By Sean McKinney, Contributing Editor

Advancing technology makes it possible to better visualize the anterior and posterior segments of the eye during, and even before, surgery. Newer ophthalmic surgical microscopes, increasingly adaptable to ASCs, provide improved illumination, better ergonomics and more compact footprints. These devices are also more efficient, provide digital recording and often can be easily networked. Below are the latest offerings from six major manufacturers.

Alcon Acquires Endure Medical Systems

With the acquisition of Endure Medical Systems, a pioneer of advanced technology, Alcon (www.alconsurgical.com) has added LuxOR ophthalmic surgical microscopes (Figure 1) to its portfolio of products available for the ASC. These microscopes deliver comprehensive, consistent visualization and user-friendly functionality during cataract surgery in the ASC, according to Alcon.

“The Endure Medical Systems full line of ophthalmic microscopes enhances our cataract surgery portfolio, offering an innovative solution for surgeons to further improve cataract surgery outcomes,” says Stuart Raetzman, head of Global Commercial Strategy, Alcon. “Cataract surgeons will appreciate the depth of perception and detail that these surgical microscopes with unique illumination technology provide.”

Alcon is launching a worldwide phased rollout of the microscopes later this year. The microscopes feature patented ILLUMIN-i technology, which allows for a stable, high-quality red reflex that is six times larger than the red reflex zone created by conventional microscopes. ILLUMIN-i also provides premium visualization and detail recognition and contrast, along with penetrating depth of focus, according to Alcon.

The technology generates collimated, non-focused light, which makes the large red reflex zone possible. A high-quality red reflex is maintained regardless of pupil size, centration, lens tilt or patient eye movement. A proprietary method of positioning the light source below the objective lens provides a long focal length while maintaining working distance, providing useful depth of focus and clear visualization.

The LuxOR Ophthalmic Microscope provides at-a-glance access to unique parameters, such as XY and focus position, via the LIBERO-XY Communication System. A full-color touch screen and wireless foot control allow customization of preferred settings for efficient setup. The illumination level, speed of focus, zooming function and XY-centering settings are all easily adjusted. Pupillary distance, initial focus point, magnification level and other settings may be saved for future use. The LIBERO-XY foot control is wireless, rechargeable, programmable and waterproof, as is the touch-screen display.

Figure 1. Alcon’s LuxOR, rolling out globally this year, allows for a stable, high-quality red reflex that is six times larger than the red reflex zone created by conventional microscopes.

Once surgeons get established with the LuxOR Microscope, Alcon is hoping they’ll opt for a portfolio of optional upgrades, including Q-VUE 3D Assistant Visualization. This enhancement features 180 degree swivel capability and an independent magnification changer. The Q-VUE 3D provides a true 3-D stereo assistant scope that doesn’t reduce light in the surgeon’s optical pathway.

More Natural Light

The OPMI LUMERA 700 (Figure 2), an ophthalmic surgical microscope from Carl Zeiss Meditec (www.meditec.zeiss.com), provides optimal visualization for anterior and posterior segment surgeries in the ASC, says the company. For the cataract and refractive surgeon, the system’s patented Stereo Coaxial Illumination (SCI) utilizes two, focused beams of light fully coaxial to the observation beam paths to produce a brilliant, homogenous and stable red reflex for optimal anterior segment visualization. Unlike collimated light, the focused coaxial illumination does not compromise visual quality, resulting in unsurpassed detail recognition, contrast and depth-of-field, says Zeiss.

Visualization is further enhanced by the company’s renowned apochromatic optics and Superlux Eye 180W xenon light source — also unique to Zeiss — which offers surgeons a whiter, more natural, higher contrast image of the surgical field than standard halogen illumination.

For retinal surgeons, the company’s proprietary RESIGHT non-contact fundus viewing system integrates seamlessly with the OPMI LUMERA 700, providing detailed visualization of the retina that Zeiss describes as exceptional in both depth-of-field and edge-to-edge clarity.

The OPMI LUMERA 700 can be configured with Invertertube E binoculars, which in addition to providing a more ergonomic sitting position during surgery, integrates motorized inverters and a tiltable binocular tube into a single form factor. When equipped with both the Invertertube E and RESIGHT 700, activation of the RESIGHT automatically results in activation of the inverters and any affiliated user profile settings — light intensity, XY movement speed, focus and zoom start values, for example — to make transitioning from anterior segment to posterior segment viewing startlingly easy. A fully integrated HD video recording system includes a 1080p HD video camera, video recorder and internalized cabling. Maintenance is simplified because no wiring is exposed. All video functionality can be controlled from the central touch-screen user interface, handgrips or wireless foot control panel. This design offers a seamless transition between video capture and other microscope functions.

Figure 2. The OPMI LUMERA 700, from Carl Zeiss Meditec, provides optimal visualization for both anterior and posterior segment surgeries in the ASC.

An integrated assistant’s microscope with independent focusing and motorized zoom can be set for independent use or linked to the zoom of the main observer. A rotatable beam splitter allows accommodation of right-sided or left-sided co-observation with the push of a button. An integrated keratoscope enables visualization of corneal astigmatism without interrupting a procedure to attach an accessory. This level of integration can substantially increase workflow efficiency and reduce overall surgery time, according to Zeiss officials.

New Haag-Streit Division

Haag-Streit USA (www.haag-streit-usa.com) has launched a new division: Haag-Streit Surgical. The new unit will market a line of surgical microscopes currently used throughout Europe. Formerly known as Möller-Wedel, the devices are now being offered in the United States under the new Haag-Streit Surgical brand.

“Now American ophthalmologists, neurosurgeons and otolaryngologists will have better access to devices with a proven record of superior optics. This launch offers a new choice for the marketplace — one that will benefit doctors and their patients,” says Ernest Cavin, CEO of Haag-Streit USA.

The surgical microscope line, including the new Hi-R Neo 900 (Figure 3), will be on display at leading conferences throughout the year.

Checking Cell Counts

Changes in endothelial cell morphology and density may indicate corneal distress, but these key indicators are difficult or even impossible to assess with standard biomicroscopy. Insight into these changes is critical for patients who undergo cataract surgery, IOL implantation and other anterior segment procedures, such as refractive surgery, corneal or lamellar transplantations and glaucoma shunt implantation. It’s important that patients with a history of fluctuating and blurry vision, foreign body sensation, photophobia, contact lens intolerance, and halos are identified when entering the ASC. These problems may go unreported or unnoticed, even though they’re associated with substantial underlying issues, such as diabetes, glaucoma, retinal disease, recurrent iritis, long-term medication use or extended contact lens wear.

Figure 3. The Hi-R Neo 900 is a surgical microscope offered by Haag-Streit Surgical, a new division of Haag-Streit USA.

Product managers at Konan Medical say the CellChek XL clinical specular microscope system (Figure 4) is a critical diagnostic imaging device, routinely used before the patient enters the OR (www.konan-usa.com/products/cellchekxl). Representing the latest in endothelial cell analytics, CellChek records the cellular image location required for understanding trends over time and critical for reliably evaluating peripheral endothelial function, says Konan. With auto-focus, auto-alignment, auto-capture and auto-cell counting, the instrument easily captures high-quality specular micrographs. Konan also exclusively includes the Center Method of analysis, which they say is regarded as the gold standard for clinical research. CellChek is easily integrated into most EMR systems and ASCs can add DICOM compatibility to simplify workflow to EMR systems at their ASC.

“With continuing changes in delivery and reimbursement, the specular microscope can have a dramatic impact in the ASC,” says Rick Torney, vice president of sales at Konan. “If you’re going to suggest a premium IOL, it’s never been more critical than today to assess the full condition of the cornea prior to surgery.”

“I’ve been surprised by the number of my cataract patients who had substantial endothelial dystrophic changes that weren’t readily visualized through the slit lamp, but were easily detectable with specular biomicroscopy,” says Ming Wang, MD, PhD, Nashville, Tenn. “Konan endothelial analysis is an important part of the work-up for all of my patients who will be undergoing cataract surgery, especially for my premium IOL patients.”

Dr. Wang says it’s important to educate patients about their preexisting endothelial conditions so that they’re fully prepared for surgery and the potential for prolonged postoperative corneal edema and blurriness as a result of corneal endothelial sub-function.

“As one saying goes, ‘If you mentioned a complication before the surgery and it occurs, then you’re a great doctor for predicting it; but if you failed to mention a complication before the surgery and it occurs, then you’re a bad doctor in having caused it,’” says Dr. Wang. “Specular microscopy is now, in my opinion, a requisite contemporary tool for all cataract surgeons who want to provide the state-of-the-art refractive cataract surgery for their patients.”

Figure 4. The CellChek XL clinical specular microscope system is routinely used to assess changes in endothelial cell morphology and density before the patient enters the OR.

“If the cell count is very low, beyond good preoperative counseling, the surgeon may weigh various schemes to further minimize the risk before or during surgery,” Torney notes. “Our customers are constantly commenting that they’re surprised by what they’d been routinely missing with the slit lamp before having a Konan specular microscope,” he concludes.

New Microscope for Cataract Surgery

Leica Microsystems (www.leica-microsystems.com/testdrive) has introduced the Leica M822 surgical microscope for cataract surgery (Figure 5), ideally suited to the ASC. Leica says the M822’s coaxial double-beam stereo illumination and OttoFlex II provide brilliant, stable red reflex and 3-D vision, even in the presence of difficult anatomical conditions, such as those associated with small pupils or advanced lens clouding.

The Leica Low Light concept has direct halogen illumination and high-intensity transmission optics, providing an excellent contrast ratio for retinal procedures, according to Leica.

Leica’s surgical microscopes are designed to integrate with commonly used wide-angle observation systems and stereo image inverters to provide an individual ergonomic fit. Depth of field is increased and XY-centering and refocusing are reduced by the double-beam stereo and OttoFlex II illumination. Brightness can be easily adjusted where needed. Leica microscopes are modular in design, meeting the needs of small clinics and operating rooms. The microscopes provide comfortable ergonomics for surgeons and assistants by offering individually adjustable binocular tubes, a wireless foot pedal, a two-in-one display, StepCycle functionality that remembers surgeon preferences and an auto-reset function. Below are highlights of the models applicable in the ASC setting:

■ Leica M822. This surgical microscope with enhanced Red Reflex meets surgeons’ demands for precise and efficient cataract surgery, minimizing discomfort while optimizing outcomes. It features apochromatic optics and a unique illumination system that combines LED and halogen for brilliant, stable Red Reflex. Floor stands provide a small base, long reach and a choice of mechanical or electromagnetic brakes for a small footprint in ORs with limited space. This microscope suits all of the surgical needs of small and mid-size ASCs and integrates with vitreoretinal accessories. Surgical workflow is optimized by a rotatable beam splitter, a two-beam path solution for a temporal approach to cataract surgery.

■ Leica M844. APO OptiChrome optics and direct halogen illumination provide exceptional clarity and contrast when using this device, according to Leica. The Leica M844 helps users see sharp, true anatomical color images at safer low-light levels. QuadZoom provides four beam paths in the same zoom system, making it suitable for teaching situations. The latest MedXchange HDMD recording technology with wireless Apple device capability for video and still image documentation is also available.

Figure 5. The Leica M822, ideally suited for the ASC, features coaxial double-beam stereo illumination.

Oculus Wide Angle Viewing System

Oculus Surgical, Inc., (www.oculussurgical.com) is now the sole provider of the SDI/BIOM non-contact wide angle viewing system in the United States. The SDI/BIOM system is used to observe the retina during vitrectomy procedures. Oculus Optikgeraete GmbH (Germany) launched the original BIOM over 25 years ago and forever changed how surgeons view vitreoretinal surgery. Oculus Surgical, Inc. has recently launched the BIOM 5 in the United States.

Made of titanium and stainless steel, the new lightweight BIOM 5c (Figure 6) features surgeoncontrolled electronic focusing and provides automatic image inversion of the SDI 4c. A new optimized reduction lens reduces the need to refocus between retina and limbus viewing. The new BIOM can be mounted in a matter of seconds and its slim design facilitates easy cleaning and sterilization. The new OCULUS BIOM HD Disposable Lens ensures a perfect view in every case, increases OR efficiency and lowers costs, according to Oculus. The company states that the BIOM 5, together with the new Oculus BIOM HD Disposable Lens, is ideal for the ASC environment. ◊

Figure 6. Oculus’ new lightweight BIOM 5c features surgeon-controlled electronic focusing and provides automatic image inversion of the SDI 4c.