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Visual operating system offers enhanced surgical experience
Microsurgical procedures can now be performed using high-definition imagery that can also be used for educational purposes.
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Digital imagery is now enabling surgeons to perform a variety of microsurgical procedures using high-definition, three-dimensional displays rather than microscopic eyepieces.
Technical advances are also helping surgeons to capture and display real-time surgery and play it back in 3-D HD to audiences for educational purposes.
Although surgeries are now being performed using 2-D video cameras and displays as secondary viewing systems in microscopy and as a primary viewing system in endoscopy, new visual systems currently on the market or available in the near future will provide surgeons with improved high-definition visualization of the eye, according to those who have experience with them.
Integration with other data
One company, TrueVision Systems, has developed a patented digital 3-D HD vision system that can be retrofitted to fit most standard surgical microscopes.
The TrueVision system integrates 3-D microscope images with other digital image sources such as CT and MRI data, according to information provided by the company. Other features include recording and retrieving data in full 3-D HD, fewer neck, back and eye injuries for surgeons, less time spent positioning surgical instrumentation and better depth of field.
The system utilizes three primary components – an ergonomic module that replaces surgical microscope eyepieces and contains two high-definition sensors that emulate the binocular system, thus providing visual depth perception; a high-powered, Windows/Intel-based workstation that receives and processes data and formats it into a dual projection system; and an image display system that consists of a foldable screen and two projectors that generate real-time images simultaneously.
Several physicians have already begun using this technology in their operating theaters. In a telephone interview with Ocular Surgery News, Douglas A. Katsev, MD, said he was surprised at how easily he adapted to the TrueVision system after 18 years of surgical practice.
Although most surgeons are used to looking through an operating microscope, Dr. Katsev said the system “allows doctors to sit in a comfortable position and move without having to have their eyes fixed on an eye piece. The view is the same as seeing it through an operating microscope. The images are much larger and projected onto a screen, and you have depth perception when using it.”
He said the device creates a different visual experience because it gives operating room personnel an opportunity to see exactly what the surgeon sees while operating.
“Everyone in the operating room can see what you’re doing. Your scrub techs are watching and can understand when you have an issue and [need] a different instrument,” Dr. Katsev said.
Some surgeons may initially be reluctant to switch to the TrueVision system, he said.
“We’re going to ask these people to think about doing something that might not be as comfortable at first because it’s different,” Dr. Katsev said. “It used to be an adjustment for people who wore loupes. Switching over to an operating microscope was cumbersome for them, and it took them a while to adjust to that. But once they realized what they could actually do with the operating microscope, they didn’t go back. That’s what I think the future will hold with this.”
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Images: Weinstock RJ |
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Image: Katsev DA |
Image: McDonald J |
‘Safe and viable’
Robert J. Weinstock, MD, initially used the TrueVision system for simple cases such as small eyelid lesions and surface diseases such as pterygium, but now he and his father, Stephen M. Weinstock, MD, have performed more than 500 cataract procedures over the past 6 months using the system.
To determine its success rate and safety, Dr. Weinstock conducted a 200 consecutive eye retrospective study of the effective phaco time, total case time and complication rate with the system. He then compared that data to 200 consecutive cases performed in another operating room that does not have a TrueVision 3-D viewing system.
“I already have some preliminary data showing that the system is safe and viable for use with no complications arising from it,” he said. “It actually has many attributes that are better and improved from the standard view through a microscope.
“We are beginning to design some software programs to overlay metric data on the 3-D screen to help guide surgeons through a procedure,” Dr. Weinstock said. “With the software, a surgeon would be able to create overlays to guide wound placement, limbal relaxing incisions and capsulorrhexis size. We would also like to create a scale system to allow surgeons to see how deep he or she is working in the eye. This would allow for additional safety, as the machine could warn the surgeon if they were getting close to the posterior capsule. The machine may actually be able to give surgeons digital and graphical information not available through a conventional microscope view.”
According to Dr. Weinstock, a second-generation unit that he is now using provides about 90% to 95% of the resolution and image quality that is seen through conventional microscopes. He said one key advantage is that it offers an almost exaggerated sense of depth of field, providing the surgeon with a better feel for the depth of the instruments inside the eye.
“It also improves how you work with your assistant and scrub tech because now they are viewing in 3-D as well. They can anticipate what instruments you will need and pass them to you more efficiently, and you can see them coming. They are much more involved in the procedure and this improves the flow in the OR,” he said. “This may translate into faster and more efficient cases, fewer complications and better care for patients.”
Dr. Weinstock said he believes that the system will eventually replace the need for surgeons to look through microscopes.
“In ophthalmology, it has some tremendous applications,” he said. “It is going to take a while just like anything else that is new. As the technology improves, it will become more and more viable. The capability of this viewing will surpass what we have through the microscope, especially when you start overlaying data on the screen.”
| When viewed on a TrueVision Systems’ 3-D viewer, 3-D high-definition images of left and right eyes appear as one image with all the stereo depth a user would see from looking into a microscope. Images: Weinstock RJ | |
Potential to change surgery
J.E. “Jay” McDonald, MD, who has been working with a prototype instrument to do cataract procedures, told OSN that the TrueVision system “has the potential to change how we all do surgery.”
He said the device could be used in a patient with brown eyes or a patient with a deep cataract. “By using some digital processing of the image, in other words a way to highlight the red reflex, like you would in Photoshop, if you wanted to bring the red out some more, you can do that,” he said.
The system also allows exact measurements and incisions by creating an overlay that can be projected onto the eye, which the surgeon can trace, he said.
“Same thing about doing astigmatism surgery at the end of the case,” he said. “We’ll program it, and it will show you exactly where to make your cuts, and it will give the tracing line for it.”
The system may help surgeons ergonomically because they will no longer be tied to the fixed settings of a microscope, Dr. McDonald said.
“Most ophthalmologists are bent over a microscope with their shoulders forward and their necks flexed, a terrible position for static muscular skeletal injuries,” he said. “It’s going to be so much better ergonomically to just sit straight or stand straight up.”
There is an adaptive process to using the system, Dr. McDonald said. More depth of field is visible than with a microscope, and he moves his hands differently when using the device.
“The other thing is, currently the images are good, but I think they can be better,” he said. “I really see the time in 5 years where we will all be utilizing these digital images … in our cataract surgery. The digital image will open all kinds of possibilities and improvements in our working in the microscopic world.”
For more information:
- Douglas A. Katsev, MD, can be reached at Sansum Clinic, 29 W. Anapamu St., Santa Barbara, CA 93101; 805-681-8950; fax: 805-568-1933; e-mail: katsev@aol.com. Dr. Katsev has no direct financial interest in the products discussed in this article, nor is he a paid consultant for any companies mentioned.
- J.E. “Jay” McDonald, MD, can be reached at McDonald Eye Associates, 3318 N. North Hills Blvd., Fayetteville, AR 72703; 479-521-2555; fax: 479-521-6761; e-mail: jaymcd@swbell.net. Dr. McDonald is an unpaid consultant for TrueVision Systems.
- Robert J. Weinstock, MD, can be reached at The Eye Institute of West Florida,148 W. 13th St., SW, Largo, FL 33770; 727-581-8706; fax: 727-586-3743; e-mail: rjweinstock@yahoo.com. Dr. Weinstock has no direct financial interest in the products discussed in this article, nor is he a paid consultant for any companies mentioned.
- TrueVision Systems can be reached at 114 E. Haley, Suite L, Santa Barbara, CA 93101; 805-963-9700, fax:805-963-9729; Web site: www.truevisionsys.com.
- John Misiano is an OSN Staff Writer who covers all aspects of ophthalmology.