Here at our surgery center in Dothan, Ala., cataract surgeons used to operate out of 2 ORs from 6 in the morning until 7 at night to handle the daily caseload. Since we couldn't add additional procedures or surgeons, we decided to triple the size of our clinical space by adding 4 ORs filled with refurbished surgical microscopes, state-of-the-art phaco machines and vitrectomy systems. Here's what we learned while hunting for the new equipment.

Surgical microscopes
We're accustomed to working with ceiling-mounted microscopes, which were necessary in our center's 2 original operating suites due to limited space. During the renovation we wanted to keep each OR as similar to the others as possible, so we decided to purchase 4 refurbished ceiling-mounted scopes at $30,000 each. When shopping for a scope, consider its:

• Set-up. First and perhaps most obvious, ceiling-mounted scopes free up valuable clinical floor space and promote case and turnover efficiencies by keeping walking paths clear. Perhaps not so obvious: Ceiling-mounted scopes are easily moved away from busy traffic areas so they're in much less danger of being bumped into and damaged than floor-mounted scopes are. That might not seem like a huge concern, but the more a scope is knocked into — however slight the bumps — the greater the chance of damaging its delicate but most important feature: the optics. We find that ceiling-mounted scopes are out of sight and out of mind between cases, which adds to their longevity by keeping the optics scratch-free and performing at a high quality.
• Illumination and optics. While some newer scopes offer xenon light sources — which are said to deliver brighter light to the surgical site — ours employ traditional halogen lights, a truly effective and versatile option. When operating on a patient with a deep-set brown iris, for example, a bright light source is needed to illuminate the eye. On the other hand, we need to turn the light source way down when working on blue-eyed patients to avoid shining too much light on the retina. Unlike xenon light sources, the halogen lights in our scopes bathe the eye in cool light and let us adapt the brightness for greater visualization and increased patient safety.
• Red reflex. The eye is comprised of 3 tissue layers, each with a distinct consistency. When operating, it's essential to distinguish between the various consistencies so you know which tissue you're working with. Look for scopes with optics that provide high-contrast, high-resolution and depth-of-field views of the eye's tissues, including red reflex enhancement.

Red reflex is the reddish-orange reflection surgeons see when observing the retina through a surgical scope. The amount of reflected light that reaches the surgeon's eye depends on the amount of light filtered through the pupil and how well the pupil is dilated. Scopes that enhance the red reflex are said to offer greater depth perception and a greater ability to see shadows within the eye, which provides surgeons with consistent and accurate views of the eye's anatomy.

There is some debate about the need to enhance the red reflex, but I've given the feature a test drive and truly liked it. Whichever side of the argument you support, red reflex enhancement seems to be the direction most top scope companies are heading.

• Ergonomics. After considering a scope's optic and illumination package, your surgeons will likely be most interested in its ergonomic features. Cataract surgery is a volume-driven business, and the brunt of that volume is often felt in a surgeon's back, neck and arms as he sits in the same position for hours on end. I'm fortunate that I haven't suffered from work-related injuries throughout my career, but part of that good fortune is owed to our scopes' ergonomic designs that let me keep my back straight while operating. Look for scopes with articulating surfaces and mechanical brakes as well as ergonomic foot pedals. Your surgeons should work in their comfort zones instead of adjusting their preferred positions to how the scope sets up and operates.

Phaco machines
We added 2 new phaco machines so our cataract surgeons could constantly rotate between ORs; adding the same phaco units in each OR keeps our surgeons operating as efficiently as possible. We also purchased a backup unit in case one of the regular machines goes down. Each unit cost us about $60,000. When reviewing a phaco unit, look at its:

• Oscillating tips. The tip of a traditional phaco handpiece oscillates at a high frequency in an up-and-down motion to break cataracts into small fragments — similar to the way a jackhammer splinters a sidewalk. Surgeons can also attack a cataract's nucleus with an ultrasonic handpiece featuring a tip that moves in a side-to-side motion at low frequency. This handpiece option generates less heat and collateral damage in the eye, and since the low-frequency oscillations don't scatter cataract fragments away from the phaco tip, the surgeon can keep the tip in one position instead of chasing fragments around the eye. That stability can increase operating efficiencies and decrease complication risks.
• Setup efficiencies. Operational performance is only part of a phaco machine's value. When shopping for a unit, consider the ways it will enable your staff to turn over rooms quickly and easily. Our turnaround time between cataract cases is less than 5 minutes, thanks in part to efficiency-minded features on our phaco units such as programmable presets, simple-to-read and understand touchscreen controls, video tutorials and easily accessible tubing and component ports. Our staff can call up a surgeon's phaco parameters with the push of a button, set up and test the machine and be ready to go in less than 2 minutes.
• Fluidics. A phaco machine's fluidics maintain pressure in the eye and remove cataract particles broken apart by the phaco tip. Two vacuum pump options exist: the traditional peristaltic and the newer venturi. Both offer advantages. Since the flow rate on a peristaltic pump is surgeon activated, it offers a controlled — some would say slower and safer — option. Venturi pumps, on the other hand, have a very strong instant vacuum and constant flow rate, which can increase surgical efficiencies in the hand of a surgeon familiar with how that steady flow feels and operates. You also have the option of providing your surgeons with a handpiece that switches between peristaltic and venturi modes, which lets them alter flow rates as needed throughout surgery.

Which pump system will your surgeons prefer? That will likely depend on the system they trained with and the flow rate with which they're most comfortable. I've used a peristaltic pump for years and will continue to do so because I'm familiar with how the flow feels and works in my hands.

Room for retina
With reimbursements for retina on the rise, we felt that now was the perfect time to add the procedures to our case mix in order to make our center a one-stop shop for eye care. In order to add the specialty, we purchased 2 new vitrectomy machines

My colleague, retina surgeon John Fortin, MD, says each unit is equipped with an embedded laser and a high-speed probe (5,000 cuts per minute) that result in safer procedures and provide precise surgeon control for better patient outcomes. If you're in the market for a new vit machine, Dr. Fortin suggests you look for a model that provides consistent control of the patient's intraocular pressure, features high-speed cutting potential and state-of-the-art illumination, and that's easy for your surgeons and staff to set up and use.