Looking into the future... Today

Insert to July/August 2016
Series No. 1
LOOKING INTO
THE FUTURE …
TODAY
Three-dimensional, high-definition visualization
is revolutionizing vitreoretinal surgery.
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It’s time to rewrite the rules of vitreoretinal surgery.
• The ULTRAVIT® 7500cpm probe provides the benefit of faster cutting and smaller vitreous bites
without fluidic compromise. 1
• Trust in integrated and stable IOP compensation 2, 3
• Helps enhance patient outcomes and achieve faster visual recovery with ALCON® MIVS platforms 4
• Increase efficiency during cataract removal with OZil® Torsional Handpiece 5, 7
• Improve your OR set up time by 36% with V-LOCITY ® Efficiency Components 6
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1. Abulon, et al. Porcine Vitreous Flow Behavior During High Speed Vitrectomy up to 7500 Cuts Per Minute. ARVO Poster, 2012. 2. Riemann C, et al. Prevention of
intraoperative hypotony during vitreoretinal surgery: an instrument comparison. ASRS Poster Presentation, 2010.* 3. Buboltz, DC. New method for evaluating flow rates and
intraocular pressures during simulated vitreoretinal surgeries. ARVO Congress Poster Presentations, 2010. Fort Lauderdale, FL.* 4. Nagpal M, et al. Comparison of clinical
outcomes and wound dynamics of sclerotomy ports of 20, 25, and 23 gauge vitrectomy. Retina. 2009;29(2):225-231. 5. Davison JA, Cumulative tip travel and implied follow
ability of longitudinal and torsional phacoemulsification J Cataract Refract Surg 2008; 34:986–990 6. Alcon data on file 954-0000-004. 7. Fernández de Castro, L. E. et al.
(2010). Bead-flow pattern: Quantization of fluid movement during torsional and longitudinal phacoemulsification. J Cataract Refract Surg 36(6): 1018-1023.
*Based on bench lab testing.
Caution: Federal law restricts this device to sale by, or on the order of, a physician. Indications for Use: The CONSTELLATION® Vision System is an ophthalmic microsurgical system that is indicated for both
anterior segment (i.e., phacoemulsification and removal of cataracts) and posterior segment (i.e., vitreoretinal) ophthalmic surgery. The ULTRAVIT® Vitrectomy Probe is indicated for vitreous cutting and aspiration,
membrane cutting and aspiration, dissection of tissue and lens removal. The valved entry system is indicated for scleral incision, cannulae for posterior instrument access and venting of valved cannulae.
The infusion cannula is indicated for posterior segment infusion of liquid or gas. Warnings and Precautions: The infusion cannula is contraindicated for use of oil infusion. The disposables used in conjunction
with ALCON® instrument products constitute a complete surgical system. Use of disposables and handpieces other than those manufactured by Alcon may affect system performance and create potential
hazards. Attach only ALCON® supplied consumables to console and cassette luer fittings. Do not connect consumables to the patient’s intravenous connections. Mismatch of consumable components and
use of settings not specifically adjusted for a particular combination of consumable components may create a patient hazard. Vitreous traction has been known to create retinal tears and retinal detachments.
The closed loop system of the CONSTELLATION® Vision System that adjusts IOP cannot replace the standard of care in judging IOP intraoperatively. If the surgeon believes that the IOP is not responding to the
system settings and is dangerously high or low, this may represent a system failure. Note: To ensure proper IOP Compensation calibration, place infusion tubing and infusion cannula on a sterile draped tray at
mid-cassette level during the priming cycle. Leaking sclerotomy may lead to post operative hypotony. Attention: Please refer to the CONSTELLATION® Vision System Operators Manual for a complete listing
of indications, warnings, and precautions.

LOOKING INTO
THE FUTURE …TODAY
Looking Into the
Future … Today
Three-dimensional, high-definition visualization
is revolutionizing vitreoretinal surgery.
Thomas M. Aaberg Jr., MD
Thomas M. Aaberg Jr., MD, is founder
and president of Retina Specialists of
Michigan in Grand Rapids. Dr. Aaberg is
a consultant to Alcon and TrueVision.
He may be reached at (616) 954 2020;
thomasaaberg@comcast.net.
Marco Mura, MD
Marco Mura, MD, is professor of ophthalmology
at the Wilmer Eye Institute, Johns
Hopkins University School of Medicine in
Baltimore, and chief of the retina division
at the King Khaled Eye Specialist Hospital
in Riyadh, Saudi Arabia. Dr. Mura is a consultant
to Alcon. He may be reached at
mmura1@jhmi.edu; drmmura@yahoo.com.
Christopher D. Riemann, MD
Christopher D. Riemann, MD, is in private
practice at Cincinnati Eye Institute and
is the vitreoretinal fellowship director at
the University of Cincinnati. Dr. Riemann
is a consultant to Alcon, TrueVision, and
Haag-Streit Surgical, and he has stock
options in TrueVision. He may be reached
at criemann@cincinnatieye.com.
JULY/AUGUST 2016 | INSERT TO RETINA TODAY 3

LOOKING INTO
THE FUTURE …TODAY
Is the entrance to your operating room a portal to the past?
When it comes to visualizing your surgical field, are you taking
a step back in time? This is entirely likely, according to several
retina specialists who have seen the future.
“Today, we have amazing imaging modalities in our clinics—
OCTs, fluorescein angiograms, ultrasounds—but as soon as we
enter our operating rooms, we leave it all behind, as we position
ourselves at a microscope that uses circa-1960 technology,” says
Thomas M. Aaberg Jr., MD, founder and president of Retina
Specialists of Michigan in Grand Rapids. “Other than the sleekness
of the design and the addition of some peripheral features,
the surgical microscope has changed very little.”
What distinguishes old technology from advanced technology
in imaging and visualization? In a word, digitization, says
Christopher D. Riemann, MD, who is in private practice at
Cincinnati Eye Institute and vitreoretinal fellowship director at
the University of Cincinnati.
“From an optical perspective, the microscopes of today are
only incrementally better than they were a half century ago,
while everything else in the OR, from our vitrectomy machines
to the music we listen to, has been digitized,” Dr. Riemann
says. “The microscope has lagged because digitizing an image
for microsurgery requires the highest quality video at dynamic
ranges and resolutions that are comparable to or better than
what we see through the microscope. That technology has only
recently become available.”
Dr. Riemann and Dr. Aaberg, who each hold degrees in
biomedical engineering, are early adopters of digitally assisted
vitreoretinal surgery, using a new 3D, high-definition, surgical
visualization platform called Ngenuity (Alcon), which converts
an optical microscope into a digital imaging system. Both
surgeons have provided input into the design and functionality
of the system for retina surgery. In fact, Dr. Riemann has
been advising TrueVision 3D Surgical, the original creators of
this technology, for nearly a decade. By 2008, he was already
performing this type of vitreoretinal surgery on select cases
using an early version of this system, and in 2010, he presented
the first retina cases using this technology at the American
Academy of Ophthalmology Annual Meeting. 1
“Back then, it was a labor of love, but there have been huge
improvements in the past 7 years,” Dr. Riemann says. “There is no
surgery that I know how to do that I would not be comfortable
doing with this system. In fact, I would prefer doing all of my surgeries
with this new digital microscopy system. It has the very best
high dynamic range, high-resolution 3D camera on the market. It
is an exquisitely powerful camera with fantastic latency.”
Dr. Riemann notes the lure of new technology is strong among
retina specialists, but to replace an iconic piece of equipment, such
as the surgical microscope, surgeons require unequivocal, tangible
benefits. “Those benefits exist, right now, today,” he says.
Perhaps the most obvious is the improved ergonomics with
digital vitreoretinal surgery.
Figure 1. After operating a full day at the surgical microscope,
Dr. Riemann often experiences neck and shoulder discomfort.
ERGONOMIC ADVANTAGE
Ophthalmologists in general and retina surgeons in particular
are at risk for work-related musculoskeletal injuries, owing
to the ergonomic hazards intrinsic to practice, such as maintaining
awkward or static postures at the slit lamp and the
surgical microscope.
“During vitreoretinal surgery, we are locked to the scope for
the duration of the operation, holding our heads in a nonphysiological
position, craning our shoulders forward, and extending
our necks, which cause musculoskeletal fatigue and wears down
the joints,” Dr. Riemann says.
In a survey of US ophthalmologists, 51.8% reported neck,
upper extremity, or lower back symptoms. 2 In a similar survey
of US retina surgeons, 55.4% of respondents reported both back
and neck pain; 21% reported back pain; and 8.3% reported neck
pain. 3 Only 15% were symptom-free. In a survey of eye care professionals
in Saudi Arabia, 70% of respondents reported neck
and back pain. 4
These statistics come as no surprise to Marco Mura, MD,
professor of ophthalmology at the Wilmer Eye Institute, Johns
Hopkins University School of Medicine in Baltimore, Maryland,
and chief of the retina division at the King Khaled Eye Specialist
Hospital in Riyadh, Saudi Arabia. “As a high-volume surgeon, I,
too, experience neck problems after a long surgery day using
the optical microscope,” Dr. Mura says. “With this new ocularfree
system, I operate in an ergonomically neutral position while
viewing a magnified image on a large monitor. I can achieve
the same results as I do when I use the surgical microscope but
without neck and shoulder pain.”
Dr. Riemann predicts his adoption of this 3D visualization system
will have a profound and positive effect on his health and
career. “I am a healthy 48-year-old, and I do not have cervical spine
problems, but I am a busy surgeon,” he says. “I operate two full
days a week, every week. If I have been sitting at the microscope
Photo courtesy of Christopher D. Riemann, MD.
4 INSERT TO RETINA TODAY | JULY/AUGUST 2016

LOOKING INTO
THE FUTURE …TODAY
Photo courtesy of Christopher D. Riemann, MD.
Photo courtesy of Thomas M. Aaberg Jr., MD
Figure 2. The ocular-free system allows Dr. Riemann to
operate in an ergonomically neutral position, avoiding neck
and shoulder discomfort.
all day (Figure 1), I am still a happy guy (after all, retina surgery is
awesome!!), but I am cracking my neck and rubbing my shoulders
because they hurt. At the end of a surgery day using the Ngenuity
system (Figure 2), I come home skipping, laughing, and whistling. I
am a happy camper. I am absolutely convinced that digital vitreoretinal
surgery will extend my career as a surgeon by 10 years.”
Although a significant benefit to the surgeon’s well-being,
ergonomics is just one of the advancements the new 3D system
brings to the OR.
DIGITALLY ENHANCED VISUALIZATION
Proper illumination is essential for visualizing the dark, microenvironment
at the back of the eye during vitreoretinal surgery,
but despite the availability of various types of endoillumination
designed for this purpose, light toxicity remains a concern.
“Phototoxicity is a real thing,” Dr. Riemann says. “It does not
happen frequently, but when it happens, it can have a significant
adverse effect on visual acuity. 5 With this new technology,
I can operate with much lower light levels than when I operate
optically. If I am performing a 27+ gauge vitrectomy through
the microscope using the Constellation Vision System (Alcon),
for example, my light pipe is usually set at 35%. For macular
work using the new 3D system, I set it at 5%. That is oneseventh
the photons exiting the light pipe and one-seventh the
light exposure to the retina—which is huge. If I can complete
the same procedure with less light, why would I choose to operate
with higher light levels?”
Researchers from Wills Eye Hospital in Philadelphia agreed
with this notion and presented data from a pilot study in which
they correlated endoillumination levels used during ocular-free
vitreoretinal surgery to subjective digital image quality and 3D
display luminous emmitance. 6 They concluded that a 3D digital
platform with real-time digital processing and automated
Figure 3. The 3D digital platform allows the surgeon to digitally
apply a red-free filter.
brightness control may allow for reduced intraoperative
endoillumination levels and a theoretically reduced risk of retinal
phototoxicity during vitreoretinal surgery.
Another major advantage of the new technology is that surgeons
can digitally enhance tissue planes by adjusting light balance
and contrast and applying digital filters, potentially reducing
the concentration of vital dye needed during surgery.
“This system brings a lot of value to the retina surgeon,” Dr.
Mura says. “Not only can I use less light, but I can also add color
digitally instead of using a staining material to see transparent
tissue. For example, the vitreous can be difficult to identify, particularly
in young patients, so I amplify the blue gain, which adds
a bluish tint to aid in visualization. When peeling the internal
limiting membrane, I digitally apply a red-free filter (Figure 3)”.
Minimizing or potentially eliminating vital dyes from vitreoretinal
surgery is beneficial on two levels, Dr. Mura says. “First,
whenever we inject something into the eye, we are performing
an extra maneuver, which has associated risks,” he says. “Second,
some of the stains we use to aid in visualization may be toxic to
the retina or cause adverse side effects.” 7
According to Dr. Aaberg, “Using what I call video chromatography
to enhance or minimize color pixels enables me
to visualize tissue planes as well as or better than I can using
the microscope and vital dyes. This makes my surgeries more
efficient with less risk of iatrogenic damage to the retina. For
my standard cases, I use a 5% illumination setting on the
Constellation and if I am using a vital dye, I can then reduce the
concentration by 50%. I can discern no difference between what
I see using this new 3D system (Figure 4) and what I see using
the usual light settings and dye concentrations with the traditional
OR microscope.”
Dr. Mura also appreciates the high magnification capability of
the monitor, which is now available with an ultra high-definition
JULY/AUGUST 2016 | INSERT TO RETINA TODAY 5

LOOKING INTO
THE FUTURE …TODAY
4K 3D display. “The resolution of images on the screen is comparable
to, and in some situations even better than, that of the
microscope,” he says. “There is a limit to how much we can magnify
the surgical field using the optical system. Once we reach that
limit, if we try to magnify the field further, we lose resolution. With
the digital system, I can enlarge the image even further to see the
microstructures of the retina with clarity.”
Another unique feature that this new, ergonomic 3D system
brings to the OR is the ability to show diagnostic imaging sideby-side
with the live surgical field. “Using a traditional microscope,
we cannot bring all of that information with us into the
OR,” Dr. Aaberg says. “We would have to look away from the
oculars to look up at another screen, and any time we glance
away from the microscope, we risk making a mistake. With
this system, I can view the surgical field on the full screen, or I
can reduce that image to two-thirds and divide the remaining
viewing area to accommodate a fluorescein angiogram and an
OCT imported from my clinic.”
REAL-TIME RESPONSIVENESS
When discussing any digital technology, particularly related
to ophthalmic surgery, the question of latency often arises.
The question has merit, Dr. Aaberg says. “Whenever software
enhancements are incorporated into digital technology, processing
times may increase, potentially creating more latency.
This is something the engineers continually address as they
work on the next generation of innovations.”
Dr. Riemann explains, “The magic number for acceptable
latency for primary digital surgical viewing is 100 milliseconds.
Many people say, ‘My goodness, that is a tenth of a second.
Is that not a really long time?’ but you have to ask a different
question. It is not that the microscope has zero latency and the
Ngenuity system has 80 milliseconds of latency. The latency of
the microscope or the digital visualization system has to be
added to the latency of human reaction time, the time that
elapses from when you see something to when your hands
act on what you have just seen. Depending on how old you
are—reaction times for kids are faster than for adults—that is
somewhere between 150 and 300 milliseconds. This means the
latency of any system must be added to the 300 milliseconds
of human reaction time. Therefore, with the microscope, the
latency is 300 milliseconds, and with this new technology it is
less than 380 milliseconds. The difference between the two is
less than 100 milliseconds.
“We also need to remember that retina surgery is slow and
deliberate,” Dr. Riemann continues. “With the current iteration
of capture, rendering, and display, there is absolutely no clinically
relevant latency.”
FAST ADAPTATION
Introducing new technology into the OR generally requires
a period of adaptation, and some surgeons may be concerned
Figure 4. Stereo image demonstrating the quality of the surgical
view using the digital 3D system with only 5% illumination and
50% less dye concentration than typically used.
about a long learning curve and its impact on outcomes. In fact,
a retrospective analysis of cases performed by a single vitreoretinal
surgeon over a 2-month period found that transitioning
from the traditional surgical microscope to an ocular-free
system did not increase surgical times or negatively affect outcomes.
8
“The transition from the optical microscope to the digital system
is fast, particularly for the new generation of surgeons,” Dr.
Mura says. “I always have my fellows test any new instrumentation.
Depending on their reactions and their adaptation times,
I decide whether it is feasible for everyone to use. What I have
seen with the new 3D visualization system is that they adapt
within a matter of hours.”
When discussing adaptation, Dr. Riemann differentiates
between “digital natives”—the millennials who never lived in a
world without smartphones, video games, and the Internet—
and “digital immigrants,” older people who migrated from the
analog age to the digital age as young adults. “Digital immigrants
usually become proficient using the system after three to
five cases,” he says. “Digital natives, on the other hand, are usually
zipping through after their first case. Fellows who are learning
surgery are usually proficient with the system within one to two
cases. Their surgical ability, not the digital visualization system,
becomes the rate-limiting factor.”
INNOVATION NOW AND IN THE FUTURE
As excited as they are about the 3D visualization system
today, these surgeons are already looking toward future
advancements in digitally assisted vitreoretinal surgery.
“In the future, we will be able to simultaneously view not
only the live surgical field but also other relevant information,
such as an ancillary video feed from an endoscope or an intraoperative
OCT image,” Dr. Riemann says. “Future innovations
may enable us to view active, real-time machine settings, such
as vacuum, cut rate, and duty cycle. I envision this system as
a multidiscipline information-handling platform, a surgical
Photo courtesy of Thomas M. Aaberg Jr., MD
6 INSERT TO RETINA TODAY | JULY/AUGUST 2016

ADVANCED TEACHING TOOL
Dr. Riemann has been teaching 3D vitreoretinal surgery to fellows
for several years. Not only are the fellows upping their game by learning
this cutting-edge technology, but both Dr. Riemann and the fellows
appreciate the learning experience afforded by the heads-up 3D
visualization platform.
“Teaching is amazing with this system,” Dr. Riemann says. “I sit 3 to 4
feet behind my fellows when they operate. They know I am there, but
I am not in their field of view, which creates a sense of autonomy for
them, decreasing their anxiety (Figure).
“My anxiety is less for two reasons,” he continues. “First, I can see
exactly what the fellow is seeing. If a fellow is using a scope that has noncoupled
zoom, I may question whether my zoom is different from that
of the fellow. Second, if the fellow is using the surgical microscope and
we need to switch places, I cannot do anything until I adjust the scope
to my pupillary distance, which is wider than average, and that takes up
to 10 seconds. With this system, the fellow places the instruments in the
trough, kicks back, and I come in. The switch is fast and seamless.”
Dr. Mura also reports that the new system is a valuable teaching
tool. “Having a large screen that allows everyone in the OR to see the
same image is beneficial for teaching purposes,” he says. “Not only can
I see what the fellow is doing, but I can also show him or her specific
tissue on the screen—where to start peeling a membrane, for example.
This is not possible when the fellow is using a traditional microscope. I
believe this improves safety during the teaching process and increases
the fellow’s confidence.
“The system also facilitates the flow of the procedure,” Dr. Mura
says. “The nurse can follow the surgery on the screen and see which
instruments will be required. When the whole team is involved in the
LOOKING INTO
THE FUTURE …TODAY
Figure. Dr. Riemann supervises fellow Cindy Mi, MD, as she
performs a phaco vitrectomy and membrane peel for a case of
diabetic traction retinal detachment.
surgical process, everyone is more focused.”
Dr. Riemann notes the latest generation of the ocular free surgery
has created an environment where he is likely to encourage his fellows
to tackle more complex surgeries. “Every one of my fellows in
the past 3 or 4 years has had the opportunity to do some of this
type of surgery,” he says. “But now that we are using next-generation
equipment with even more refinements, I am comfortable allowing
them to do more. The ergonomics make sense. The workflow is
good. The system is user friendly. You turn it on, you white-balance
the camera, and you are good to go for the day. Our fellows, who are
all millennials, sit down and they just do it. It is beautiful.”
Photo courtesy of Christopher D. Riemann, MD
cockpit that will give me the information I want, where I want
it, when I need it.”
Dr. Aaberg notes that TrueVision initially introduced its visualization
system to the neurology specialty, and prior to bringing
it to retina, it was already being used by cataract surgeons.
“One of the first applications for the anterior segment was the
ability to overlay corneal topography onto the surgical field,
enabling the surgeon to precisely orient toric intraocular lenses
and astigmatic corrections,” he says. “Imagine if we could project
a fluorescein angiogram directly over the surgical field to
guide laser treatment of an area of nonperfusion and have this
image register to and track with the live surgical image.
“The next quantum step for us as retina surgeons will not
be how we do surgery, but how we view surgery,” Dr. Aaberg
continues. “Digital microscopy will give us the opportunity
to use all of the forms of retinal imaging that we have grown
accustomed to using in our clinics—and probably retinal imaging
that has not even been invented yet—and to bring them
into the OR.”
Dr. Riemann concludes: “This system is revolutionizing
retina surgery starting right now, but in 10 years, we will
look back and wonder how we ever performed surgery while
looking through a microscope. I have no doubt that digitally
enhanced visualization of the retinal surgical field will dramatically
improve the efficacy and safety of the entire family
of vitreoretinal surgical procedures.” n
1. Riemann CD. Machine Vision and Vitrectomy: Three-dimensional High-definition Video for Surgical Visualization in the Retina
OR. Poster presented at: American Academy of Ophthalmology Annual Meeting; October 17, 2010; Chicago, IL.
2. Dhimitri KC, McGwin G Jr, McNeal SF, et al. Symptoms of musculoskeletal disorders in ophthalmologists. Am J Ophthalmol.
2005;139:179-181.
3. Desai URT, Abdulhak MM, Bhatti R. Occupational Back and Neck Problems in Vitreoretinal Surgeons. Paper presented at:
American Society of Retina Specialists Annual Meeting; August 2004; San Diego, CA
4. Al-Marwani Al-Juhani M, Khandekar R, Al-Harby M, et al. Neck and upper back pain among eye care professionals. Occup Med
(Lond). 2015;65:753-757.
5. Youssef PN, Sheibani N, Albert DM. Retinal light toxicity. Eye (Lond). 2011;25:1-14.
6. Thornton S, Adam MK, Ho AC, Hsu J. Endoillumination levels and display luminous emittance during three-dimensional
heads-up vitreoretinal surgery. Poster presented at: Annual Meeting of the Association for Research in Vision and Ophthalmology;
May 4, 2016; Seattle, WA.
7. Gandorfer A, Haritoglou C, Kampik A. Toxicity of indocyanine green in vitreoretinal surgery. Dev Ophthalmol. 2008;42:69-81.
8. Barakat M. Learning to Use a Stereoscopic Display With Retinal Surgery Does Not Increase Surgical Time or Negatively Affect Outcomes.
Poster presented at: 2016 Annual Meeting of the Association for Research in Vision and Ophthalmology; May 4, 2016; Seattle, WA.
JULY/AUGUST 2016 | INSERT TO RETINA TODAY 7

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