EnVision Summit 2023: Tech Savvy: Top 5 Tech Tools in the OR

Nadia Haqqie, MD, considers a 3D microscope, a markerless alignment system for toric intraocular lens (IOL) implantation, and more as some of the most important tools in the OR. (Image courtesy stock.adobe.com)

Having the best tools available is of the utmost importance in the operating room (OR). For Nadia Haqqie, MD, those include a 3D microscope, a markerless alignment system for toric intraocular lens (IOL) implantation, the Zeiss OMPI Lumera/Rescan 700 microscopes, Zepto precision pulse capsulotomy, and Zeiss Veracity Surgery Planner.

Dr. Haqqie, assistant director, Wills Eye Emergency Department, Philadelphia, explained the pros and cons of the various instruments at the Envision Summit, Puerto Rico.

The 3D heads-up microscopes, Alcon NGENUITY and Zeiss ARTEVO, include a 3D high dynamic range camera attached to the microscope. The camera heads have 2 sensors for stereopsis and alignment. The instruments include polarized 3D glasses for the surgeon andobservers and a 55-inch 4K ultra-HD organic light emitting diode display.

The potential advantages are the decreased power of the endoilluminator and reduced phototoxicity, ease of use in difficult patient positions, improved ergonomics, and engagement of the OR staff. The disadvantages are the high cost ($85,000), the learning curve and increased surgical time, and delayed image processing.

Markerless alignment systems for toric IOLs, ie, Zeiss Callisto Eye, which transfers data from the IOLMaster, and the Alcon Verion Digital Microscope Marker, which transfers data from the Argos biometer eliminate manually marking of the eye. This capability ensures proper alignment of overlays regardless of eye movement/rotation, capsulorhexis customization, and takes the anterior chamber depth and the visual axis into account to provide accurate centration of the capsulorhexis and IOL, Dr. Haqqie explained.

A comparison of the Alcon Digital Marker System (cost, about $17,000) with manual marking showed that the marking and time required to do so with the digital marker system were superior to manual marking both in lower toric IOL misalignment (2.0 ± 1.86 degrees versus 3.4 ± 2.37 degrees; p=0.026) and alignment time (37.2 vs. 59.4 seconds), resulting in an overall shorter surgical time (727.2 digitally versus 1,110.0 seconds manually), she reported.

The uncorrected distance visual acuities were similar between the 2 groups.

The Zeiss surgical microscopes are the OMPI Lumera and Rescan 700, with intraoperative optical coherence tomography (OCT) imaging capability. The Rescan 700, when used for anterior-segment surgery can assess grafts during corneal transplantation and potentially decrease the graft manipulation time, help delineate corneal thickness and position of the air cannula in lamellar keratoplasty, and assess depth during corneal biopsy. During posterior-segment surgery, the instrument can assess membrane peeling and macular hole closure, identify locations for chorioretinal biopsy, and assist in locating the targeted area for gene therapy, Dr. Haqqie described.

The major drawbacks are the cost ($150,000-$350,000), no reimbursement code, and lower image quality compared with the in-office OCT.

Zepto Precision Capsulotomy ensures precise creation of the capsulotomy. This device has a single-use, disposable handpiece that is placed through the main wound, ie, a minimal 2.2-mm incision. The silicone suction shell has a flexible nitinol ring that delivers thermoelectric energy and a center suction shell around the first Purkinje image. The instrument delivers 12 micropulses of energy (<5 msec) resulting in instantaneous cleavage of the anterior capsule and around capsulotomy about 5.2 mm in diameter. At completion, the device is removed through the main wound.

The advantages over a femtosecond laser are lower cost, less disruption of surgical flow, and a stronger capsulotomy edge. The device is useful in difficult cases of, for example, white cataracts.

However, the costs are high, $20,000 for the portable console and $200 for each single-use handpiece. Early reports of radial tears and incomplete capsulotomies prompted improvements and modifications. The company has also implemented a comprehensive training program to ensure technology proficiency.

The Zeiss Veracity is a refractive cataract planner that is cloud-based and integrates medical records, diagnostic devices, and surgical plans. It provides surgeons with the ability to create a customized note for each surgery. The postoperative refractions can be incorporated into the system and used for outcomes analysis and optimization of the IOL constants. Use of this technology decreases the risk of transcription errors, Dr. Haqqie explained.

Some strong advantages are its potential to automate the plan and suggest an IOL, easy adjustment of the refractive target, alerts that the patient may be post-refractive, and may help recommend against implantation of a premium IOL.

Nadia Haqqie, MD,

Nadia Haqqie, MD

Haqqie is a board-certified ophthalmologist with the Wills Eye Cataract and Primary Eye Care Service and Wills Eye Emergency Department. She serves as a Clinical Instructor of Ophthalmology at Sidney Kimmel Medical College at Thomas Jefferson University.