If you're thinking of buying a new ophthalmic microscope, whether to outfit a surgical startup or to upgrade your existing ORs, most manufacturers will bring their latest offerings direct to you for demonstrations and trials. But I always recommend that surgeons and administrators visit association conferences to check out the scopes on the exhibit hall floor as well. That way they can test them all, back to back, and compare the advantages and disadvantages of each while the trials are fresh in memory, not spread out over the course of several weeks. Here are a few more tips to keep in mind if you're in the market for an ophthalmic surgery microscope.

Cost and consideration
The essential workings of the surgical microscope haven't radically changed over the past 20 years. It's still all about optics and illumination, and how they work together to provide sharp, quality images. Plus, many ophthalmic surgeons tend to remain loyal to the manufacturers whose microscopes they're familiar with.

However, surgeons have been known to jump on the bandwagon for new equipment and instruments at the introduction of new features and the latest technology, the budget notwithstanding. Many hospital-based surgeons still might not overly concern themselves with the cost of their wish lists.

But the thing that really changes surgeons is when they're the owners of surgical facilities. When they're responsible for the center and its budget, and equipment outlays are coming out of their own pocket, they look at what they're getting for their money. Is the new scope better? Is it cost effective? Will it improve patient care or the speed with which procedures are performed? Is this latest advance important technology, or just a toy? What adds value to a practice or center? These are questions you should also consider.

Light and image
For those reasons, the biggest innovations at present have drawn something of a divided response.

In terms of new and advancing microscope technology, illumination is at the forefront. Direct halogen light has traditionally been used in ophthalmic scopes due to the fact that the surgeon isn't dealing with deep cavities. But the introduction of a filtered-down xenon light, a brighter and whiter light, in some scope models has expanded the boundaries of illumination.

Xenon lighting is often found in microscopes specialized for spine surgery, where the longer focal length of the scope requires brighter light. One manufacturer whose eye scope integrates xenon illumination says it lets users view the anatomy of the eye in natural color, given xenon's whiter light and the tendency of halogen to add a slight yellow tint to the subject it illuminates.

But the jury's still out on xenon technology among some quarters. Some surgeons argue that it's too bright of a light and might do damage to the optic nerve. Others note its high heat output and the cost of bulb replacement.

Another advance has been in microscopes' video capabilities. Surgical documentation through streaming video has become common in cataract, refractive and glaucoma procedures for research, patient information archiving, clinical presentation and patient education.

Three-chip cameras, some with high-definition resolution, and digital capture devices seem to be on their way to becoming standard components in ophthalmic scope systems. Three-chip, or three-CCD (for charge-coupled device) cameras enable a higher image quality, since they process the red, green and blue light — the color components of video imaging — of a subject separately, as compared to a single-chip camera, in which one CCD measures all three colors. Digital capture devices process the cameras' signals and store the resulting images. They can be used in conjunction with a surgical facility's servers or computer workstations.

Despite the advantages and benefits available in video documentation, however, not every surgeon is recording his procedures, and not every surgeon wants to. Also keep in mind that recording in high-definition requires a full slate of high-definition-compatible hardware — from an OR's data cabling to the monitor to the processing equipment — to get the full effect of viewing and presenting. (See "The Value of Video" on page 52.)

Motion and mounting
The technology may not be as flashy as illumination and video are, but a microscope's handling and positioning abilities are without question vital to its use during the delicate moments of eye surgery.

Many microscopes now employ electromagnetic brake systems for more refined handling. Smoother and easier to handle than mechanical brakes, the advance provides more precision and flexibility in scope positioning as well as more stability in holding. The free-floating stands adopted by many floor-mounted eye scopes in emulation of spine and neurology scopes have made repositioning even more user-friendly.

As an alternative to floor stands, you also have ceiling-mounted scopes. If you're outfitting a room dedicated solely to ophthalmology, you might consider this option, but there's a lot about ceiling-mounted scopes that can make a buyer pause.

As with an equipment boom, you've got to plan for it in advance, preferably before the construction of the room, or else you might face significant renovations to retrofit your ceiling with a supportive structure. You also lose a lot of flexibility if you choose a ceiling-mounted model. Once you suspend a microscope from the ceiling, it stays there. If it breaks down or if it would be convenient to use in another room, its lack of mobility means you're out of luck. Additionally, if you're in a building with an occupied floor over the OR's ceiling, there's always the concern that vibrations from above may affect the scope's stability. Overall, I'd recommend that only if you're severely limited for floor space should you rule out floor-stand microscopes.

The case for reconditioned
More and more buyers in the surgical marketplace have capitalized on reconditioned or refurbished equipment. There are several reasons for this trend.

Perhaps the most obvious is the discounted pricing. You can obtain a reconditioned unit for 25 percent to 50 percent less than the original retail price. The quality of pre-owned microscopes has also vastly improved in recent years. Due to institutional turnover, a large number of newer models have found their way to refurbishers and are supplying the increased need of smaller facilities and practices for this type of equipment.

Additionally, many surgeons prefer to use tried-and-trusted models of microscopes, many of which can be obtained in "as-new" condition with favorable warranties. And, since ophthalmic scopes are a type of equipment that can be reconditioned to high quality, there's a motivation for ophthalmic surgeons to save money on their microscope purchases to free up capital for investment in other, brand-new instruments such as phaco machines, lasers and video equipment.

If you're considering the reconditioned market, be sure to research the quality of the supplier, its products and its warranty. What kind of follow-up support do they offer in terms of the cost of parts and labor? What will repairs cost you? The warranty should span at least one year: If you have a flawed piece of equipment, you'll know it in that time. And see if you can obtain a copy of the original manufacturer's manual, for reference on operation, troubleshooting and warning signs. It's not uncommon for reconditioned equipment to come without it.

Carl Zeiss Meditec
OPMI Lumera i
(800) 342-9821
www.meditec.zeiss.com/lumera
Price range: $50,000 to $150,000
FYI: Carl Zeiss Meditec's new OPMI Lumera i offers a breakthrough in surgical integration efficiency, says the company. In addition to its revolutionary red reflex, high contrast and depth of field created by the patented Stereo Coaxial Illumination, it offers a universal touchscreen control panel, integrated camera control unit for one- or three-chip cameras, a 50 percent higher X-Y range and a new ergonomic foot pedal.

Endure Medical
Reflex Microscope on E7 Floor Stand
(800) 736-3873
www.enduremed.com
Price range: starts at $30,000
FYI: Endure Medical's Reflex microscope offers high resolution, wide-field optics for depth of view and a variable red reflex module, says the company. The E7 floor stand features a digital touchscreen control unit with presets for up to eight surgeons. All motorized functions are remote-enabled and the unit can be re-centered via a waterproof footpedal.

Leica Microsystems
M800 Series Ophthalmic Surgical Microscopes
(800) 526-0355
www.leica-microsystems.com
Price range: $69,000 to $125,000
FYI: Leica Microsystems highlights its M800 series ophthalmic microscopes for their consistent and reproducible direct illumination; the QuadZoom feature, which provides 100 percent stereoscopic vision and illumination for both surgeon and assistant; a variety of ErgonOptics binoculars, which allow all physicians to work comfortably at the microscope; the auto reset function, which enables time savings during room turnovers; and Leica's new, exclusive, MedXChange HDMD high-definition video system.

Moeller-Wedel
Moeller Hi-R 900 Series
(513) 899-4455
www.moeller-wedel.com
Price range: $40,000 to more than $100,000
FYI: Moeller-Wedel's Hi-R 900 Series of ophthalmic microscopes, sold and serviced in the U.S. by MD Microsurgical (www.mdmicrosurgical.com), feature high-resolution apochromatic optics, a strong red reflex and rapid zoom, focus and X-Y movements, says the company. Models 900 and 900A feature integrated slit illumination, while models 900SL and 900SLA have integrated slit lamps.

Prescott's
Omni-Flex
(800) 438-3937
www.surgicalmicroscopes.com
Price range: $36,000 to $42,000
FYI: Prescott's Omni-Flex is a dedicated cataract microscope which combines high-quality German optics with a simple, easy-to-use, American-built floor stand for a superior operating system, says the company. The optics, designed and supplied by Haag/Streit, feature apochromatic lenses and a red reflex enhancement system, while Prescott's microscope stand presents physicians with an ergonomically correct unit.

Topcon Medical Systems
OMS-800 OFFISS Surgical Microscope
(201) 599-5122
www.topconmedical.com
Price range: Not disclosed
FYI: Topcon's OMS-800 Optical-Fiber-Free Intravitreal Surgery System microscope allows surgeons to perform bimanual vitrectomies and other types of retinal surgery without the need for handheld fiber optic illumination, says the company. The unit also features a double-focusing mechanism, electromagnetic locks and a programmable multi-function footswitch.