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Steve Charles, MD Steve Charles, MD Viewpoint of a vitreoretinal surgeon T he NGENUITY 3D Visu- alization System is a major paradigm shift. I bought the first NGENUITY 3D Visu- alization System in the U.S., paying for it out of pocket because I saw so much value and potential in it. I've been using it exclusively since November 2016. Vitreoretinal surgery requires 3D visualization. Because NGENUITY has paired small aperture CMOS sensors, it pro- vides greater depth of field. This allows me to maintain focus despite a patient's up-down head motion driven by respiration, an issue more pronounced in patients who are overweight or have COPD. With five times greater depth of field, the sur- geon can maintain distance accom- modation and avoid accommodation fatigue. The surgeon's image brightness, and therefore contrast, is virtually independent of patient macular light exposure, which is a safety advan- tage. A high dynamic range OLED display allows for photopic (all cone vision), rather than mesopic (cone- rod vision) as with a traditional microscope. Cone, or foveal, vision allows the surgeon to see high spatial details. Another benefit is the huge 55" surgical display just 4 feet away. This surgical display offers image quality that continues to the corners of the plane. Typically, when you look through an operating microscope straight in, there is high-quality focus without much optical aberration. But if you look just a little above, below, left, right, the image quality dete- riorates. Being able to see all four corners in perfect focus is a different experience. Now I'm able to look around on the field of view without moving the microscope; I am able to follow the folds in the retina and visualize membranes on the retinal surface, and I have better situational awareness. While these are the core surgical and clinical benefits of NGENUITY, there are other ben- efits to this huge surgical display. Now everyone in the operating room can see the same view as the surgeon. Team coordination is mark- edly improved. If nurses see bleed- ing, they might offer me cautery or ask if they should increase intraoc- ular pressure without me having to mention it. This has improved our OR efficiency. For vitreoretinal surgery, NGENUITY populates with information from the CONSTELLATION Vision System, such as vacuum level, IOP, mode, brightness, and a variety of other things. Each of the four corners of the screen has useful information, so instead of asking a scrub tech or trying to see the CONSTELLATION screen, which is too small and too far away, you can look right on the NGENUITY display, giving you more awareness of what you're doing throughout the case. This has been called by some "heads-up surgery." The operat- ing microscope blocks the view of the surgical display if it is placed directly in front of the surgeon. This requires it to be a little off to the left or right. I think calling it heads-up surgery is a misnomer, but I do con- sider it digitally assisted surgery. When first getting started with NGENUITY, it's important to have the surgical display set up properly. It has to be 4 feet away, not 10 feet away at the end of the table. Sec- ond, you have to have the aperture at the 30% mark, or you don't get the increased depth of field. Finally, when doing vitreoretinal surgery, you have to initially focus on the cannulas, then focus down as you remove more and more vitreous and get closer to the cannulas. When you finally get on the retinal surface at the highest magnification, you opti- mize focus again. n Editors' note: Dr. Charles is the found- er of the Charles Retina Institute in Germantown, Tennessee and clinical professor of ophthalmology at the Univer- sity of Tennessee. He can be contacted at scharles@att.net. it created. Scrub nurses, circulators, even anesthesiologists are more engaged during the surgery, and my scrub nurses are better able to anticipate what I might need next during a case because they feel more involved. It has also been a great surgical teaching tool for suturing with my residents and fellows. The system allows you to watch the surgery back in 3D, so I can get into the details of each surgical step. I think this is true even for teaching new techniques to our colleagues, and I am excited to see where this could go as we get more and more video recordings using the NGENUITY system and playback in 3D at conferences. n Editors' note: Dr. Brissette is an assistant professor of ophthalmology at Weill Cor- nell Medicine in New York. She can be contacted at asb9040@med.cornell.edu. NGENUITY 3D Visualization System •Up to 5 times extended depth of field* •Up to 48% increased magnitude* •Up to 42% increased resolution* •Digital filters to enhance visualization, facilitate operating at lower light levels •55 inch OLED display with 8.3 million pixels of resolution •Ocular-free design improves posture and may mitigate surgeon fatigue *Alcon data on file, December 2017 continued from page 6 MAY 4, 2019 | SUPPLEMENT TO EYEWORLD DAILY NEWS | 7

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