In 2016, when TrueVision 3D Surgical partnered with Alcon, the way of viewing retina surgery changed.

With the launch of the NGENUITY 3D visualization system, we ocular-dependent retina surgeons were propelled into the future. Before this new system, the surgical setup had required viewing through the oculars of an operating microscope. And while we had great success with this older setup, the operating microscope with oculars has a few drawbacks, mostly with the ergonomics and bodily strain of the actual procedure, which are most pronounced after a long and intense day in the operating room.

With this new system, retina specialists are able to sit back and view the surgery on a 4K 55-inch OLED monitor using 3D glasses, creating a platform for ultra high-definition digitally-assisted vitreoretinal surgery (DAVS). In addition to improved ergonomics of operating, the Ngenuity system provides all participants in the operating theater the same view, allowing everyone on the team to better learn, and work, together.

THE SETUP

What everyone needs to remember is that the operating microscope you already have is going to be used with this platform. The first thing one notices is that the oculars have been removed and replaced with a 3D camera, which is wired to a new computer, or central processing unit (CPU), based in the microscope stand. The CPU processes two overlapping stereo images from the live surgery. The image displayed on that 55-inch monitor provides 3840 x 2160 pixel resolution; with the passive polarized 3D glasses provided by the manufacturer, every member of the surgical team can view the surgical feed stereoscopically. The 3D glasses come in multiple designs, including clip-ons for those surgeons who already wear spectacles.

After the initial startup costs, no further fees are required for continuing to operate the Ngenuity system.

THE BENEFITS

Besides the “wow” effect of using this platform, additional benefits become apparent once the surgeon begins using the system. Its impact on both surgical efficiency and surgeon ergonomics quickly become evident.

The system’s enhanced depth of field allows multiple image planes to remain in focus. When increasing magnification, the image enlarges without compromising optimal viewing. Furthermore, low levels of endo-luminescence, while the system maintains a superior image, are made possible by electronic amplification of the camera’s signal; this reduces the theoretical possibility of phototoxicity from the light pipe. Adjusting the iris aperture on the camera allows easier bimanual treatment of a diabetic tractional retinal detachment with the aid of a chandelier by creating a brighter image with a lower level light source. In repair of a macular hole, lower concentrations of intraocular dyes are often used. Color filters manipulate the image, permitting better visualization of vitreous body and retinal hemorrhages.

MARKETING AND TRAINING POSSIBILITIES

John Kitchens, MD, of Retina Associates of Kentucky, uses the Ngenuity system as a marketing tool for his practice. He invites referring doctors (both ophthalmologists and optometrists), into the operating room to view retina surgery. Dr. Kitchens explains, “They see the surgeries that we do, the same way that I see it, in 3D. They are better able to appreciate how we do our surgeries and the intricacies involved with them.”

The system holds approximately 100 hours of surgical videos. Editing videos is less burdensome than was previously the case due to the smooth interface and computer operating system, which allows the surgeon to create videos for educational purposes. When training residents and fellows using the traditional microscope, the assistant’s view is of lower quality compared to the surgeon. This is not the case with the Ngenuity system. The 55-inch screen is positioned at the foot of the operating bed, which allows everyone to view a clear, panoramic image of equal quality. This point is crucial when training the next generation of vitreoretinal surgeons.

TAKING THE STRAIN AWAY

We feel the ergonomics benefit of this platform cannot be overstated. We all know that the profession of ophthalmology places strain on our bodies.¹ Long operating days looking through a microscope with a slightly bent-forward posture can leave the surgeon with neck and back pain. This discomfort can be ameliorated with a heads-up approach to surgery, in which the operating surgeon can maintain a more natural upright position, producing less strain.¹

When using the Ngenuity system, the surgeon can maintain a comfortable position, actually sitting back in his or her chair.

SOME FINE-TUNING REQUESTS

As with any new technology, a few limitations exist with Ngenuity. While the potential is there for: post-image manipulation; utilizing preset filters and color channels; and improving visualization of certain tissue planes and intraocular structures; the reality is that the Ngenuity platform needs a bit more fine tuning. The current preset filter and color channel schemes are limited; while they do help in certain cases, we cannot claim they do so in all situations.

Alcon and TrueVision are working on additional preset filters and dynamic, real-time, surgeon-controlled image adjustments to facilitate these points in upcoming software update iterations. Additionally, though the learning curve is minimal, one should probably expect to use the system on approximately 10 cases to get the hang of it. Furthermore, while the system does provide increased visualization and stereopsis in most cases, certain scenarios do present the sort of pitfalls for which first-time users of the system must be aware. Though suturing can be difficult at first, it becomes easier to perform after several cases.

Operating in an eye with a multifocal lens presents a potential challenge of stereopsis, which has been anecdotally reported by some surgeons. The slight gradation in refractive power between the optical zones of the multifocal IOL, which may go unnoticed in traditional ocular-based surgery, appears to become augmented when magnified on the monitor, causing a slight change in depth perception particularly while working in the periphery. While it does not preclude using the platform in these cases, first-time users should be aware of this potential effect and adjust accordingly.

CONCLUSIONS

“Heads up,” 3D digitally-assisted ophthalmic surgery is not a passing fad. Whether the NGENUITY platform is ready to replace ocular-based surgery, even in its current iteration, and become a “must have” system, is up for discussion.

Nevertheless, we believe this new technology is a game-changer in the field of vitreoretinal surgery and that it can greatly enhance the surgical experience for all parties. At the very least, it represents the first step in the digital evolution of surgical visualization as we know it.

Though we focus mostly on the retina advantages to this platform, cataract and glaucoma specialists have incorporated Ngenuity into their practices with great success.¹

The future is promising for heads-up 3D vitrectomy, with further advancements inevitable. Real-time image manipulation, in addition to intraoperative integration with other imaging modalities, such as OCT, angiography and endoscopy, represent some of the future advances that are sure to emerge from this technological paradigm shift. Furthermore, less expensive, more versatile and fully digital microscopes are likely on the horizon. OM

REFERENCES

1. Eckardt C, Paulo EB. Heads-up surgery for vitreoretinal procedures: an experimental and clinical study. Retina. 2016;36:137-147.
2. Weinstock RJ. Operate with your head up. Cataract Refract Surg Today Eur. 2011;8:66,74.

About the Authors

Carl Danzig, MD is the director of vitreoretinal services at Rand Eye Institute in South Florida, and an affiliate assistant professor at Florida Atlantic University-Charles E. Schmidt College of Medicine.

Jorge Fortun, MD is an assistant professor of ophthalmology at Bascom Palmer Eye Institute, where he serves as medical director of the ambulatory surgical center.

Disclosures:
Dr. Danzig reports no financial relationships with any of the companies mentioned in this article.
Dr. Fortun has been a consultant to Alcon.