DROPDOWN A ceiling-mounted scope offers many ergonomic advantages, says Dr. Hendricks.

I was happy with our ophthalmic microscopes, but when they got so old that the original manufacturer discontinued service on them, we felt it was time to see what else was available. I expected to see some improvements, but what I saw far exceeded my expectations. The improvements are not just window-dressing — they truly can make care better and more efficient, and improve the experience for everyone, including the surgeon, the staff and the patient. Here's a look.

1. Better red reflex
Over the last 10 years, nearly all microscope makers have vastly improved their lighting so that a significant part of the light travels to the retina and reflects back. This improved indirect lighting improves the contrast and shadows, and makes it much easier and more efficient to work inside the eye. For me, this improvement stands out above all the others. The size, consistency and quality are amazing.

Seeing better helps me work faster and better. When I'm doing a capsulorhexis, for example, and something starts to go wrong, I can see it and correct it much earlier. It helps when I'm polishing the capsule after lens removal, too. It also eliminates a lot of the repositioning that used to be endemic to the procedure. With my old scope, it was important for the staff to keep the patient positioned so that the irises were parallel with the plane of the floor; any tilt could cause a loss of the red reflex. I also periodically had to move the scope from side to side — so-called XY movement — to keep it centered. The new technology is much more forgiving.

A high-quality red reflex also helps during femtosecond laser cases, because sometimes those reduce the size of the pupil. It also works well with our ORA system when we do aberrometry. We're able to capture the image quickly without multiple tries.

A better red reflex can even save money. We used to use a lot of trypan blue with patients who had dense cortical cataracts. But the contrast is so good with the new scope that the cortical cataracts show up as black instead of white.

2. Heads-up display
Two of the newest microscope systems can display key information about the patient and the procedure right through the eyepieces as well as on the screen, so you have a lot of the information you need to do the procedure. On ours, I can see all the microscope settings in my field of view. I just look up and see my light settings and my X, Y and Z coordinates, and make sure that the scope is set up according to my preferences before I start the case. If I need to change them, I can do it with the foot pedal without asking anyone. It's much quicker than before.

Used to its fullest, this technology offers a lot more promise. It can connect to the diagnostic instruments in the ophthalmologist's office and then display key clinical information through the eyepieces as well as the video screen, so the surgeon can very conveniently have a lot of the information he needs to do the procedure. For example, if the patient has astigmatism and you'll be inserting a toric IOL, you can see the axis of astigmatism superimposed right over the image of the eye so that you can orient the lens correctly. If you'll be correcting astigmatism with arcuate incisions, the technology can show you where to make them. It can also show you the changes you've made in corneal curvature in real time. This promises to be much quicker and more convenient than having the patient sit at the slit lamp to mark the cornea before the procedure.

CUTTING-EDGE FEATURES
Can Your Microscope Do This?

Newer ophthalmic microscopes include a wealth of other helpful and innovative features. Here are some worth considering:

• Cataract suites. No more marking patients. New systems transfer data taken from the office scan into the scopes' eyepieces. The result: more precise and accurate placement of toric IOLs.
• Focal length. Longer (up to 60mm longer) focal lengths than the traditional 175mm means more depth of focus and less surgeon strain.
• Software options. You can turn scopes on and off in seconds with software that doesn't run on typical operating systems. When operating systems reside on flash disks, they can't be corrupted by viruses.
• Illumination. The high-contrast light produced by xenon has a better color rendering index and is closer to natural daylight than halogen (and some scopes can provide both). Using a lower light level for retinal procedures can reduce the risk of macular phototoxicity.
• 3D recording and editing. With 3D-equipped systems, surgeons can manipulate the 3D functions with hand and foot controls, so workflow isn't interrupted. Some systems can simultaneously stream both 3D and 2D video to external video monitors.
• Automatic invertible binoculars. With this feature, user profile settings are stored and binoculars can automatically transition between preferred settings for cataract and retinal procedures.

— Jim Burger

3. Assistant scopes
Microscope makers have made major advances in assistant scopes. It used to be that any device — whether it was an assistant scope, a camera or an ORA system — shared the surgeon's light and diminished our view. Now, many models are able to give all the devices brilliant lighting, making for fantastic images. With our new scope, if I'm doing a paracentesis and need my assistants to place iris hooks, both are able to do so with no problem at all.

The new assistant scopes also offer much more flexible positioning. In the past, when an assistant was particularly tall or short, it was difficult for her to get in a position where she could do something as precise as, say, cutting a suture. Now, it's easy.

Another nice feature: You can rotate the new assistant scopes. If you happen to be doing right eyes in the room and then a left eye comes in, you just pivot the head and rotate the assistant scope. You used to have to take the surgeon's oculars off to rotate it. Now it just spins from one side to the other.

4. High-resolution recording
With our old scope and camera system, there were times when I'd mention a small pupil or a dense cataract and people in the room would say they couldn't see it on the monitor. Now, if I have a resident or a rep in the room, they can see everything. They know what to do next and what we're going to need next, because the resolution is so good. That, too, has a lot to do with the red reflex.

I don't need to record a lot of cases. But when there's something new or really interesting, it's nice to have that option. When we first got our new system, I did my first laser cataract procedures with a proctor who recorded them and put them on a flash drive. As it happened, I was giving a talk at Tulane University a month later. She said, "Here they are, in order." That was really helpful.

5. Surgeon comfort
Ergonomics have been a major problem with ophthalmic scopes for years. A number of surgeons have been forced to undergo neck surgery because they spent long hours in awkward postures to do eye surgery. Today there are options. Some microscope makers offer adjustable eyepieces so that the surgeon can sit in the upright position, no matter his or her height. Virtually all have wireless foot pedals that let you easily change the scope's settings without looking up. Some offer technology that shortens the working distance for retinal surgeons. One relatively new technology places the microscope image on a screen, so that surgeons don't have to look through the microscope optics at all. We happened to decide on a ceiling-mounted scope, and I think it has important ergonomic advantages. Everything's usually in place by the time I sit down, but when I have to move the scope myself, I can simply reach up, grab it and move it.