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innovations advancing cataract surgery 6 | SUPPLEMENT TO EYEWORLD DAILY NEWS | MAY 4, 2019 Ashley Brissette, MD Ashley Brissette, MD Visualization in cataract surgery T o achieve ideal visualization for cataract surgery, there are many settings for the oper- ating microscope that need to be optimized—depth of focus, accommodation minimization (especially true for trainees), illumi- nation, magnification, ergonomic positioning, etc. If these are not neck pain over our long careers. We just opened a top-of-the-line surgery center at Weill Cornell Medicine, and the NGENUITY 3D Visualization System is one of the new technol- ogies that we incorporated into our surgical suite. Our retina faculty were the first to jump on it, but I've started using it for the past few months for anterior segment surger- ies—cataract, cornea, conjunctiva— and have been impressed with the system, both from a visualization standpoint but also in limiting my neck discomfort at the end of a long OR day. I have a personal interest in ergonomics, and the more I talk to my colleagues, the more I realize how important physician well-being is to career longevity. I think the forward positioning of the operat- ing microscope is a contributor to back and neck pain. Even for longer procedures, I find NGENUITY extremely beneficial to have not only improved depth of field and other visualization benefits but also being able to maintain a comfortable position. The first time I tried the system, I found that I was sitting and leaning forward just like I do at the microscope. I had to remind myself that I can sit back and break those old habits. When first getting started using NGENUITY, I made sure to try it on a less busy OR day so that I could play with the settings, color balance, and other features to get comfortable with the technology. I find the image resolution sim- ilar to that of high-definition TVs and computers. The peripheral acu- ity is something that I was surprised to find I was missing with the analog microscope cases, especially in my cornea and conjunctival procedures. I find this feature gives an improved depth of field to the total operating space. In addition, the enhanced depth of field helps to maintain focus throughout a case so that you aren't adjusting to keep structures in focus. Take, for example, a highly myopic eye with a deep anterior chamber. Normally, you would be adjusting the fine focus through- out the case as you reach down for nuclear pieces to bring to the iris plane for phacoemulsification, but with NGENUITY you can main- tain the focus across this expanded space, which is especially helpful for challenging cases. Our retinal colleagues are al- ready comfortable with this tech- nology, but I think anterior segment surgeons will adopt it in time. It's been great as well for longer cas- es such as corneal transplants. An unexpected effect of NGENUITY in my OR is the team environment NGENUITY 3D Visualization System Source: Alcon continued on page 7 Dr. Brissette operates off the NGENUITY 3D Visualization System screen. Source: Ashley Brissette, MD fine-tuned at the outset, many ad- justments may be needed during the surgery, which is not ideal. There have been some improve- ments to visualization in cataract surgery in recent years, for example, the quality of the optics and ste- reo coaxial illumination for the red reflex. This allows you to see every fine detail of the anatomy, even in complex cases, while not needing to increase the amount of light. I think this helps with patient comfort and safety as well. However, it can still be dependent on patient movement or tilting during the case, as the depth of field is limited with some micro- scope platforms. While there have been advances in the realm of optics and illumina- tion, just thinking about sitting at the microscope for a long OR day makes my neck hurt. I think we are getting better at recognizing the im- portance of ergonomics in surgery, but our work environment puts us at high risk for developing back and

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