ADDED BENEFIT Consider surgeon satisfaction and the potential for improved outcomes when assessing scope add-ons.

Eye surgeons need the best visualization from their microscopes to be able to operate with the highest precision. You can improve the functionality of your ophthalmic scope by equipping it with accessories that go beyond conventional visualization. But which of the latest upgrades are worth the investment? We asked several surgeons about which add-ons help them operate efficiently and comfortably, and which enhance outcomes.

1 Wide-angle viewing systems. During retinal detachment cases, wide-angle, non-contact viewing systems let surgeons easily refocus from the posterior segment to look more anteriorly with the simple press of a foot pedal. This gives them clear views of the peripheral retina, where tears tend to occur.

"Conventional contact lens systems provide a limited view of the retina," says Jason Hsu, MD, a retina specialist at Wills Eye Hospital in Philadelphia, Pa. "The systems we use provide a larger field of view. Being able to more easily identify tears in the periphery of the retina certainly helps."

There's another benefit, says Dr. Hsu. Surgeons no longer have to rely on assistants to hold conventional contact lens systems steady for extended periods during critical parts of procedures.

2 Heads-up 3D displays. Surgeons who work with heads-up displays wear passive 3D glasses, which provide eye-popping views on a big-screen monitor. The technology separates surgeons from the microscope, meaning they don't have to remain hunched behind the oculars for hours on end. Besides the view, you'll benefit from improved ergonomics. "You can shift your body around to get comfortable instead of having to remain in a static position," says Dr. Hsu.

Eye surgeons are still warming up to heads-up 3D displays, says Dr. Hsu, one of the few Wills Eye docs to regularly use the "cool technology." While visualization is good, Dr. Hsu says it's not yet on par with a microscopic view.

But even the early generations of heads-up imaging let surgeons complete surgical tasks they might not be comfortable performing with a microscope. For example, when performing macular work, surgeons typically put a contact lens viewing system on the eye, but the field of view becomes limited to the central 30 degrees of the retina.

EASY ON THE EYES Heads-up displays improve surgeon comfort and provide images of anatomy beyond what microscopes can offer.

"As they're peeling the macula, surgeons don't want to pull their forceps out of the field of view," says Dr. Hsu. "Heads-up displays provide a very wide view of the retina beyond the macula, so they can see where their instruments are at all times. That makes the peel much more efficient and safer."

With heads-up displays, surgeons can also enjoy great views of anatomy while using very low levels of illumination, because images can be digitally enhanced and brightened on the screen. Dr. Hsu typically performs 25- or 27-gauge surgery with a light setting around 40%. With the heads-up display, he works with a light setting of only 10%, a reduction in output that reduces risk of photo toxicity caused by light shining off the retina, especially during longer cases.

Heads-up displays can also improve case efficiency. OR staff can watch the action unfold on the displays and prep instruments and medications before surgeons ask for them. "They're able to anticipate the surgeon's next move much more quickly than they can when standard microscopes are used," says John Miller, MD, director of retinal imaging at Massachusetts Eye and Ear in Boston.

Color and lighting filters can highlight various eye tissues in ways that aren't possible with standard microscopes, adds Dr. Miller.

3 Intraoperative OCT. This technology, which provides surgeons with real-time snapshots of vitreoretinal pathophysiology during retinal and corneal procedures, is the gold standard for retinal diagnosis in the clinic, says Dr. Miller, who adds that there are barriers to optical coherence tomography's widespread use in the surgical setting. "It's slowly being incorporated into the OR, although there are issues with cost and how to best integrate the technology with the microscope and the flow of the operation."

Dr. Miller says iOCT is helpful during cases when the vitreous membrane has multiple layers. "Being able to rely on the microscopic detail provided by OCT to tell exactly which plane you're working in is a plus," he says.

Dr. Hsu finds iOCT helpful when he treats vitreomacular traction syndrome, which can result in small holes forming in the macula. Surgeons who perform vitrectomies to treat the condition typically err on the side of caution by inserting a temporary gas bubble into the eye to put pressure on macular holes and allow them time to heal. The insertion of the bubble causes blurred vision and requires patients to remain in a head-down position for 2 weeks post-op. Dr. Hsu says intraoperative OCT lets surgeons visualize the retina to ensure no holes formed. They use that key information to avoid inserting the gas bubble and subjecting patients to a grueling recovery.

Surgeons currently work with intraoperative OCT as an overlay of their surgical view in microscopes, and it takes up a large area of the screen, says Dr. Miller. "Surgeons often check the OCT, resume surgery and then check the OCT again," he says. "It's a pause-and-play technique." He foresees integrating intraoperative OCT into the large screens of heads-up displays. "You can imagine a user-friendly, picture-in-picture format," he says. "As OCT technology gets better, more surgeons will use it to guide their maneuvers."

4 Wavefront aberrometry. Cataract surgeons rely on these real-time readings of refractive data to correct astigmatisms and optimize IOL power for both aspheric and toric lens implants, and ultimately to improve refractive outcomes, says Kathryn Hatch, MD, site director at Massachusetts Eye and Ear, Waltham, and an assistant professor of ophthalmology at Harvard Medical School in Boston, Mass. She says the technology helps surgeons fine tune their toric and spherical power for patients who want to do away with glasses after surgery.

She uses wavefront aberrometry when implanting toric lenses in order to rotate the IOL into proper axis alignment and to properly titrate limbal relaxing incisions. "It plays a significant role in correcting astigmatisms, dialing in spherical power and in treating post-LASIK patients, even those with extreme axial lengths," says Dr. Hatch.

The technology is helping surgeons meet the demands of the growing number of patients who want improved post-op vision, she says. "We're in an era where patients expect spectacle independence, and surgeons are using everything at their disposal to make that happen," says Dr. Hatch. "Wavefront aberrometry isn't a standalone solution — it's one more tool surgeons use to optimize refractive outcomes."

She was an early adaptor of wavefront aberrometry and currently uses it in more than half of her surgeries. But her reliance on the technology might not be the norm; Dr. Hatch says less than 20% of cataract surgeons use it regularly.

"There's a learning curve, and the platform adds several minutes to case times," says Dr. Hatch. "But the more you use it, the more efficient you become with it. You have to look at the big picture," she continues. "Wavefront aberrometry is a worthy investment if refractive cataract surgery is important to your surgeons. Nowadays, I can't imagine that it's not." OSM