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Is It Time to Upgrade Your Ophthalmic Microscope?
A look at the features that can improve the efficiency of today's new scopes.
Nathan Hall
Publish Date: October 27, 2008   |  Tags:   Ophthalmology

If you're close to replacing the trusty ophthalmic microscope that has outlasted and outperformed every other piece of equipment, and person, in the OR, you'll want to know which new features are available today and worth having. Here's a sampling:

Floor-mounted stands. Looking for an alternative to a ceiling-mounted scope? Los Altos, Calif., cataract surgeon David F. Chang, MD, suggests a floor-mounted scope, citing the improved stability and design of floor-mounted stands. "These stands are excellent now," he says. "For the price, I don't think that ceiling mounts offer any major advantages anymore. The only exception would be if the OR is too small to accommodate the floor-stand footprint."

More ergonomic designs. Many newer scopes are designed to be easier for surgeons and staff to use. It wasn't so long ago, an industry source reminds us, that you had to have a nurse move around the microscope and tighten friction screws to position it. Now you've got electronic brakes that release easily, so you can move the free-floating head.

One of the main innovations here is the magnetic clutch, says Dr. Chang, which lets surgeons manually position and reposition the microscope with sterile handles. "We no longer have to pre-position the scope before scrubbing," he says. "This saves a lot of time, and it lets the surgeon adjust the microscope position independent of OR staff."

Bright and controllable light. Your surgeons may prefer xenon illumination because it's said to provide a clear view of the different colors in the eye. In general, manufacturers say that there's also much better light transmission today, meaning that the amount of light that reaches the surgeon's eyes is much greater than it used to be.

Advanced foot pedals. During phacoemulsification, the phaco foot pedal controls the irrigation, aspiration and ultrasonic power delivery. The foot pedals on newer microscopes give more control to physicians who are doing anterior and posterior chamber work. "With the magnetic clutch and the ability to adjust my illumination level with my foot pedal, I no longer rely on the circulating nurse to make adjustments during surgery," says Dr. Chang. Some newer microscopes have systems that let you electronically compensate for the inverted images by making alterations with the foot pedals, adds Donald J. D'Amico, MD, professor and ophthalmologist-in-chief at Weill Cornell Medical College at the New York-Presbyterian Hospital. Gina Stancel, surgical administrator for David C. Brown, MD, at the Eye Centers of Florida in Fort Myers warns, however, that the "heavily promoted" programmable foot pedals that change with each part of the procedure aren't that interesting to the faster cataract surgeons.

High-resolution video systems. With the high demands of teaching, documentation and research, the ability to have a high quality video recording system or a live feed to remote locations is important, says Dr. D'Amico. He says that the video view on one new microscope rivals the view an assistant has looking through the binoculars. "So in a teaching situation, instead of having two or three people craning their necks to get a look through a port, the image can be displayed on a screen," he says.

Touchscreen controls. While it may be convenient to be able to easily see all the controls and capture images with a touch, this may not have much of a real benefit on the actual surgery for most facilities. Your surgeons may prefer to simply move the scope into the field rather than fiddle with a touchscreen, say the experts we consulted. But for someone like Dr. D'Amico, who shares his microscopes with as many as 60 colleagues, touchscreen controls have a definite advantage. This feature lets each surgeon set up a customized start-up screen to input settings that will automatically put the scopes to their own personal preferences for focus, zoom, illumination and other settings. Dr. D'Amico calls this "an enormous time saver."

Is Your Scope Obsolete? Here Are 8 Ways to Tell

Even if your physicians are happy with the image they're getting, ophthalmic surgeon Paul Arnold, MD, in Springfield, Mo., says you may want to consider an upgrade if your scope lacks these eight essential features.

  • Enhanced red reflex. You want a good light reflection in the eye to see how severe the problem is. "The denser the cataract, the less of a red reflex you're going to see," says Dr. Arnold. "As you clear the cataract out, you get a sharper red reflex."
  • Off-axis light source. Having a non-perpendicular light can increase the details of features in the eye, says Dr. Arnold, particularly the iris, the capsule and the lens.
  • Automatic centering. A scope that can automatically return to the center of its X-Y axes with the touch of a button will save a lot of time between cases. "Sometimes, if you get a patient who moves a lot during surgery, your scope gets moved to extremes," says Dr. Arnold. "If you start another case without re-centering it, then you're stuck in a corner."
  • Remote X-Y control. With this feature, a nurse or another staffer watching the operation can watch a video screen and keep the scope focused on the eye so the surgeon can concentrate on the procedure.
  • Adjustable eyepieces. These are particularly important if you have several surgeons using the same system, because it lets them get a comfortable view of the surgical site.
  • Adjustable headpiece. This feature allows the surgeons to put the microscope in a setting that's best for them, whether they like looking straight ahead or having it angled down a few degrees.
  • Stereo observer setup. Surgeons who work in teams should have a second headset to let their assistants watch what's happening.
  • Digital camera port. This is invaluable for facilities that record their procedures for marketing or educational purposes.

- Nathan Hall

Sharper contrast. Apochrom-atic lenses are said to greatly improve visible details.

Angle of illumination. Some microscopes offer ways to alter the angle of illumination relative to the viewing angle. However, says Dr. Chang, "I am not convinced that the average surgeon can tell a real difference in the red reflex by doing this."

How do you know it's time?
Ophthalmic microscopes last a long time. You might have to purchase just one in your career. But how do you know when it's the right time for you to upgrade?

One sure sign is when it costs as much to repair as to replace. Increasingly expensive maintenance wasn't the only reason the surgeons at Windham Hospital in Willimantic, Conn., decided to replace their microscope after 20 years of service, says OR nurse Karen LeDuc, MS, RN, CPN, CNS. "As it was getting older, the visuals were going," she says. Her facility bought a new system for ophthalmology procedures, but the staff still uses the older one for orthopedic procedures.

Another sign is when parts are hard to come by. When clinical director Robin Williamson, RN, and her staff moved into the Stony Point Surgery Center in Richmond, Va., in 2003, they didn't take their 20-year-old scopes with them. "It got to the point where, when things broke, you couldn't get new parts for them," she says.

Even if your scope still functions fine, what your surgeons see when they look through it may not be up to par with the current standards. This was the reason that Dr. D'Amico replaced his facility's two-decade-old microscopes this year.

"The most important aspect of any ophthalmic surgery is visualization," says Dr. D'Amico. "This is the single most necessary feature for a new purchase, and in my experience it dwarfs all the other factors, from size, cost, portability or anything else the microscope might offer."

Manufacturers are also working on ways to improve the way images are processed. The most recent innovation is the OPMI Lumera platform from Carl Zeiss Meditec, which uses stereo coaxial illumination to provide bright light directly back to each of the surgeon's eyes to provide clear edge-to-edge red reflex that defines all the details with high contrast, says a Carl Zeiss Meditec spokesperson.

"Previous systems often worked well on some eyes but had difficulties with, for example, darkly pigmented eyes, small pupils and high myopes," he says. "We challenged our engineers with re-inventing the phenomenon of red reflex. We said it should be bright from edge to edge, rich in contrast and detail recognition, and significantly increase depth perception, and it should work equally well on all eyes."

Dr. Chang says it took him a few cases to adjust to the OPMI Lumera technology. After that, he says he realized that he was seeing details and depth that he hadn't ever seen before. "I liken this to comparing standard television to high-definition TV and, in the same way, after trying the latter it's a bit disappointing to go back to the standard image," he says.

Surgeons tend to be creatures of habit, so the odds are pretty good they're going to want to go with a brand they already trust. This is exactly what happened when Ms. LeDuc went shopping for a new microscope. "We had good service with our vendor and their product had longevity, so I believe that was the only one we tried," she says. "The surgeons gave us some parameters they wanted to go with about visualization, how easy it'd be to change the settings such as the magnification, light and position, its height and other features. They also wanted to try it out, which we were able to arrange."

Despite her good experiences with one vendor, Ms. LeDuc recommends looking at more than one brand and not to keep that a secret. "If the representatives know you're looking at more than one option, the prices can change a lot," she says. "Competition is a good thing sometimes."

While shopping, stick to brands you know and make manufacturer support an issue, says Ms. Stancel. "Look for service packages that guarantee prompt attention, because you can't really 'punt' when your scope is out of service," she says. "Service packages should include periodic calibration." She adds it's important to see how much replacement lights will cost over the years to better assess the scope's true cost.

Finding the right scope may mean a trial. You could have vendors set up their scopes in your facility or, like Ms. Williamson, check out several types by going on a tour with your surgeons to visit facilities to test different models. "Administrators need to involve physicians in the decision because they're the ones who are using the microscope," she says.

When looking at the cost, Dr. Chang says it's important to resist temptation to buy the least expensive option. "A top-drawer microscope improves OR efficiency and surgeon performance," he says. "When you consider cost differences, you must amortize them over thousands of cases each year."