Ophthalmic surgery technology is heading swiftly toward a smarter, more communicative, and multidimensional future.

“In many respects, ophthalmology surgery changes quickly. And in some respects, it changes relatively slowly,” says Lawrence Woodard, MD, an ophthalmologist at Omni Eye Center in Atlanta, GA. “There’s not a lot that’s ‘new’ right now, but there are things on the horizon to get excited about.”

Surgery in Three Dimensions

One of the most exciting is the advent of threedimensional (3D) surgery. While it may not be “Avatar” or “The Life of Pi” special effects, 3D surgery promises a new level of comfort and depth of visualization that cannot be matched by the standard 2D approach.

“It’s not exactly ‘hot off the presses,’ but 3D surgery is as high-tech as it gets right now,” Dr. Woodard says.

“Imagine doing 20 or 30 surgeries for 8 to 9 hours per day, looking through the microscope the whole day. Your head aches, it’s fatiguing on your neck, and, because you’ve got to stay very still, you become more tense and more fatigued overall,” he says. Virtually all those issues disappear when a surgeon can use a camera-equipped microscope and wears 3D glasses to watch and guide his hands and instruments via a high-definition TV monitor.

“We still have our hands in the eye like normal. However, we’re looking at the screen, and so we have more flexibility with our body movement and our neck position. That makes it much less painful and fatiguing,” he notes.

Delivering a greater depth of field than even the best available microscopes, which are still confined to 2D views, 3D surgery has been developing for ophthalmology only in the past few years. But Dr. Woodard says vendors like Alcon (NGenuity) and Zeiss (Artevo 800) are already taking it to a higher level. Video overlays, for example, display the data required to complete cataract removal on the TV screen, much like the heads-up capabilities found on jumbo jets and high-end cars.

“The screen itself will show me how much astigmatism the patient had preoperatively, how long their eye is, or any other data I find it important to know in the midst of the surgery,” he says. “The technology is customizable in terms of the information we want to visualize during surgery, and that’s very exciting.”

3D Benefits for Surgical Staff

Today’s 3D systems also let surgical staff view the procedure more easily. Instead of having to look past the surgeon’s arms and hands, they can also view the screen, enabling them to anticipate instrument needs.

For example, 3D capability enables a surgical tech to anticipate the imminent need for an iris hook or epi-Shugarcaine for a patient with floppy iris syndrome. Another example is when the surgeon breaks the posterior capsule during cataract removal, necessitating vitrectomy. The staff can begin gathering the necessary materials even before the surgeon voices his request.

“Better visualization helps the OR staff better anticipate what the surgeon will need,” Dr. Woodard says.

The 3D technology is advancing in other ways. During its early days, there was a significant lag between the surgeon’s movement inside the eye and when that movement appeared onscreen. “That lag can throw us off, as surgeons, so most people weren’t comfortable with 3D,” he says. “But now, the technology’s improved to where there’s essentially no lag present.”

3D surgery remains very much in its infancy; Dr. Woodard estimates that less than 5% of ASCs currently offer it. “But it’s definitely going to increase over time,” he says. “There’s no question that it is the future.”

The March Toward Interoperability

Other advances in the ophthalmic surgery, particularly with respect to cataract surgery, focus on bringing greater interoperability to the ASC. A longstanding desire of ophthalmologists—like many other specialists—has been to work with EHRs, biometers, phaco machines, femtosecond lasers, and other technologies that can communicate with each other to streamline surgical planning, execution, and outcomes measurements.

P. Dee G. Stephenson, MD, FACS, ABES, FSEE, of Stephenson Eye Associates, Venice, FL, cites Zeiss’s Veracity as one example. The platform automates much of the refractive process, going so far as to import diagnostic and other data from the patient’s record and assist surgeons in selecting the intraocular lens most appropriate for a given patient.

“Veracity has really come into its own,” says Dr. Stephenson. “The beauty of it is that there’s no human error. It directly takes the information from your EMR, and it helps you pick the power of your lenses.

“It also knows what your toric alignment needs to be when implanting a particular IOL” she adds.

Dr. Stephenson explains that prior to her acquisition of Veracity, “we had to write out a list [of needs] based on whether the patient was having femto or manual cataract surgery, whether they have a small pupil, what their steep axis is, and other factors. Veracity helps you to determine the power of the IOL based on individual diagnostics done preoperatively that is saved in your patients EMR record.”

Dr. Stephenson also cites the advantages of interoperability with respect to astigmatism correction. Her LENSAR Laser platform is compatible with the Pentacam and the Cassini Analyzer, which can both wirelessly transfer preop diagnostic data to the femtosecond laser, permitting precise astigmatism treatment planning via intelliaxis marks on the capsule and cornea, and takes into account cyclotorsion buy registering the iris.

“This technology has given me the ability to improve my residual astigmatism to less than a half a diopter and eliminating potential transcription errors,” she says.

Smarter Surgical Suites

Some manufacturers are pursuing interoperability even further, through the development of technologies that connect the entire continuum of ophthalmic surgery—from diagnosis, planning, and performance, all the way through outcomes measurement—with one all-encompassing platform.

“A big part of [accurate and efficient] surgical treatment is having access to all that information from one place. Good surgical planning software will integrate all of the various tools that we have,” says Dr. Woodard.

Perhaps the most visible of these efforts is that of Alcon, whose work-in-progress, Smart Suite by Alcon, is intended to provide cloud-based, end-to-end, seamless integration of patient records, diagnostic data, surgical instrumentation, and outcomes analysis software. Built on the Philips HealthSuite digital platform, Smart Suite is expected to be fully compatible with currently available surgical equipment such as Centurion, ORA, Verion, and LenSx.

“The Smart Suite takes cataract surgery from the beginning, all the way through every aspect of the surgical procedure, and on to your postoperative data collection and management,” says Dr. Woodard.

“It takes the planning process to the next level. Information acquired by the aberrometer is then sent back to the surgical planning module, so that when the postoperative [outcome] data is entered for the patient, the information from surgery is already in the system,” he says, adding the system saves time and reduces or eliminates many errors.

“Instantly, you’re saving your staff a lot of time, as well as capturing every piece of information that’s possible,” Dr. Woodard says, adding that all of the data can be viewed on a tablet or other handheld device.

“Everything from diagnostic reports to the patient’s electronic health record is available at our fingertips with a tablet,” he adds.

A Paradigm Shift in Eye Surgery

The technology being used in ambulatory surgery centers has come a long way in recent years, and the future is certain to bring even further advances in the sophistication and capabilities of ASC technology.

“I’m definitely very excited about the future,” Dr. Woodard says. “I feel like we are in the early stages of a significant paradigm shift in how we plan surgeries, taking it from a manual process to a much more automated process. It’s going to dramatically shift how the OR day is planned, how our technicians are managing the day, and how efficient our ASC and ASC staff will be.”

Dr. Stephenson agrees, but she also cautions that the ultimate value of surgical technology lies not only in how advanced it is, but also in whether it helps makes for a better surgeon. ■