Christopher D. Riemann, MD, Cincinnati Eye, Cincinnati, OH, presented the first scientific poster outlining his 3D surgical experiences with DAVS, Digitally Assisted Vitrectomy Surgery, at AAO 2010 in Chicago. He started his evaluation with the TruVision system in 2008 – 2009 as it became feasible to have quality of visualization in heads-up surgery. According to Dr. Riemann, “there has to be a happy convergence of technology in order for digital heads-up surgery visualization to work including chip sets capable of generating and displaying high frame rates, excellent dynamic range, and high definition resolution, with a delay of less than 100 milliseconds.”
RetinaLink had the unique opportunity to interview Dr. Riemann and Alan J. Franklin, MD, PhD, Mobile, AL, to understand DAVS better, why their retina colleagues should evaluate this technology and why it will be the future in retina surgery. Dr. Riemann said, “it’s an evolution, look at music, LP records, 8 tracks, cassettes, mp3 and now, you download your personal playlist in crystal clear digital high fidelity on your smart PHONE. In my opinion, 3D, Heads-Up Surgery, has also evolved and is becoming the standard for visualization during vitreoretinal surgery.”
RetinaLink (RL): Please outline your early surgical experiences with NGENUITY®.
Christopher D. Riemann, MD (CDR): The technology has become optimized. Honestly, the early 2008 software and hardware were not very user friendly. We spent quite a bit of time hanging out in front of projectors adjusting all sorts of camera settings manually. But that was 10 years ago. I love the technology now. The white balance is quick and easy and the memory setting is good. The enhanced next generation software and vastly improved hardware allow me to turn the system on and immediately start operating. The initial reasons I stuck with the earlier versions of the technology were the teaching benefits for fellows and oberservers, the coolness factor, and most of all , the fact that I could see better – especially for macular work. even with early versions of digital surgical visualization technology, stereoacuity and depth of field were both superior to the microscope so I ended up being be faster in the eye.
Alan J. Franklin, MD (AJF): When I demoed NGENUITY, I knew immediately I had a better depth of field and quite frankly, I had a better level of precision. I can change the color settings to either suppress vitreous opacities such as hemorrhage, or enhance the vitreous for removal.
CDR: My patient had a very sick at risk eye. They presented with advanced glaucoma, c/d 0.9 and an existing pars plana tube, ERM, macular pucker, retained crystalline lens fragment. I decided to use 27-gauge and I needed ICG. I opened the camera aperture all the way which allowed for minimal illumination, my lightpipe setting was 5. With the green boost setting, I needed one quarter of the dilution normally needed. So, the minimal light intensity and exposure to ICG dye greatly reduced both potential light and chemical toxicity.
RL: What would you tell your colleagues when they first evaluate NGENUITY?
CDR & AJF: Younger surgeons will adopt DAVS quickly. They grew up playing video games so not using oculars comes naturally since they automatically look at the screen. Their transition may only take one case., For older surgeons – and that’s what “we” are now – the transition to new technology may initially seem a little daunting. But there is no need to be afraid.
CDR: The first case may be a little clumsy. However, current generation DAVS technology is really great after you get to know it… give yourself 2 to 3 or even 5 cases. At that point, you won’t encounter difficulty. The absolute KEY pearl is to “fill the screen with the circle.” Zoom up so the screen is filled with the pupil or wide angle lens. This way you use all the pixels at your disposal.
AJF: The stereopsis you will experience with DAVS mid-vitreous is impressive. The posterior pole will be in focus and the magnification will provide an extra layer of depth perception and surgical precision. I’m overwhelmed by how much you see and can do with additional information. The low light capabilities with an open camera aperture allow us to operate with light pipe settings of 5% on the Constellation or 20% on EVA. When we close the camera aperture, depth of focus is incredible. We see a great view with the cornea, iris, posterior lens capsule and macula all in perfect focus. This is perfect for “pole to pole” surgery for trauma.
RL: Why is DAVS the future for retina surgery?
CDR: I believe we will have better patient outcomes with DAVS compared to analog technology (the microscope oculars). We now can see better than with the microscope and the digitalization of the primary surgical image will allow us to manipulate the view we have to show us what we need to see in an enhanced format when and how we need to see it. Digital red free settings, (Alan has been a pioneer with this), green or blue boost settings for membrane peeling, high contrast settings for enhanced vitreous visualization, and picture in picture simultaneous display of auxiliary video feeds (from intraocular endoscopy, intraoperative OCT, and preop diagnostic testing) are all possible right now and are just the beginning of this technology. DAVS creats a digital information handling cockpit that greatly enhances the surgeon’s decision making, efficiency all while reducing light levels and probably enhancing patient safety.
AJF: DAVS allows me to do my job better and I operate better. To use the transportation analogy, I can drive a horse and buggy or my car. I do get better results with the car.
We are putting together a small pilot study to look at quantitatively lower light settings in eyes that are at higher risk, eg. Underlying AMD, for light toxicity following macular surgery. I had patient about six to eight months ago with GA, and a lamellar macular hole and cystic change with visual deterioration from 20/60 to 20/100. After surgery in eyes with this pathology, the resulting VA with analog technology would remain at 20/80 to 20/100. I used DAVS and had better visualization with lower light exposure as Chris and I have outlined. That patient’s VA is 20/60 and holding. This doesn’t happen with analog. We are planning a pilot study to compare vision as well as several OCT biomarkers following macular surgery with either analog or DAVS visualization in eyes with AMD to hopefully demonstrate a quantitative protective effect of DAVS for macular surgery.
Chris Riemann has been a pioneer with this technology and I agree with him that all our retina colleagues will be using DAVS in the future.
Dr. Christopher Riemann can be reached via e-mail, email@example.com and Dr. Alan Franklin can be reached via e-mail, firstname.lastname@example.org