Two Australian ophthalmologists speak to Insight about why they are excited about the double-release of new ARTEVO microscopes from ZEISS – even though they focus on entirely different segments of the eye.
Two instruments caused the most buzz on the ZEISS booth at the recent RANZCO Congress in Adelaide – and both for the same reason.
When most manufacturers pour their efforts into microscopy technology, it can take years to emerge with a single state-of-the-art system, but ZEISS has made a splash in the local market with two distinct microscopes under its ARTEVO product line.
Whether you’re an anterior or posterior segment surgeon, ophthalmologists are excited about the potential of this technology to bring a new edge to their surgical work.
After releasing what it describes as the industry’s first digital microscope (the ARTVEO 800 in 2019), the ARTEVO 850 is the company’s latest innovation in heads-up 3D visualisation surgery, something that has been popular in the vitreoretinal space.
Meanwhile, the ARTEVO 750 is its latest microscope targeted mainly at cataract surgeons, building on the success of its LUMERA technology that has long been a standard-bearer in operating theatres across the country.
Intraoperative OCT (iOCT) is a key feature in both technologies, along with a host of other innovations that vitreoretinal surgeon Professor Andrew Chang and cataract surgeon Dr Georgia Cleary had first access to in Australia.
In the vitreoretinal surgeon’s hands
In the weeks leading into the RANZCO Congress, ZEISS put the ARTEVO 850 into the hands of Prof Chang, head of ophthalmology at the Sydney Eye Hospital and medical director of Sydney Retina Clinic.
He was impressed on several fronts. Not only does the heads-up display promote better posture, but he can perform retinal surgery with a magnified stereo view, wearing 3D glasses that bring all-important depth perception to his work. In fact, surgeons can boost this by 60% using the new Smart DoF function.
An improvement ZEISS has made for the ARTEVO 850 is true colour representation, with more than 1 billion colours used to represent the surgical field in natural colours. This is thanks to a high dynamic range (HDR) monitor and two 4K three-chip cameras, projecting the surgical image in high fidelity on a 55-inch screen.
With the surgery easily viewable to everyone in the operating room, Prof Chang says theatre support staff can more readily respond to the surgeon’s needs and trainee doctors can learn more effectively.
“The surgeons can also move from anterior to posterior segment very easily on the ARTEVO 850,” Prof Chang says, referencing the AutoAdjust function that automatically changes the settings when switching between the two.
“The other advantage is the Hybrid Viewing System, allowing you to wear the stereo glasses to view the magnified image in stereo on the screen, and still maintaining the ability look down the oculars of the operating microscope to perform certain parts of the surgery.”
With advances in technology, Prof Chang observed that “latency” issues on the heads-up display are greatly reduced. In earlier versions of these microscopes, he says surgeons had to adapt to a slight lag, but ZEISS had overcome this with improved computing power and technology.
Speaking at a ZEISS-hosted breakfast at the RANZCO Congress, Prof Chang walked through recent surgeries using the ARTEVO 850 where, in many cases, iOCT was crucial to macular surgery. For example, showing the fine layers of the neural macular and confirming successful removal of retinal membranes just several microns thick.
“Amazingly, the iOCT just passes through [vitreous] fluid, and even though we have stained the membrane blue, the OCT still shows you the precise neural structure. It’s reached a point where iOCT images are virtually as good whilst in surgery as those we obtain in the clinic.
“The other benefit of the ARTEVO 850 is the ability to change the colour of illumination, for example enhancing the colour blue can help to better visualise retinal membranes.”
Here, he’s referring to the Digital Color Assistant function to accentuate anatomical details.
Prof Chang highlighted a diabetic patient who, despite previous laser, suddenly lost vision and could only see hand movements. He had a diabetic tractional retinal detachment and vitreous haemorrhage, making it difficult to visualise the macula.
“But when I positioned the iOCT over it, you can see the traction bands and where they are attached, showing where to dissect tissue and target precisely where the traction is located. The macula might be covered with blood, but the iOCT shows that the macula is spared so this patient should recover vision after surgery.”
He expects the ARTEVO 850 to shine in other areas, such as gene therapies administered by subretinal injection, as well as tPA injections for submacular haemorrhage.
iOCT is crucial to ensuring the surgeon is accessing the precise retinal layer.
But its capabilities go beyond vitreoretinal surgery, with other ophthalmic subspecialists able to benefit.
“Our anterior segment colleagues find the iOCT very useful when performing DSEK as they can ensure that the graft is in place. Glaucoma surgeons benefit from the high digital magnification when they precisely place their stents,” he says.
“It’s a game-changer for posterior segment work, but the ARTEVO 850 is excellent for anterior segment surgery as well. This technologic platform allows us to work from front to back of the eyes seamlessly, safely and effectively.”
Cataract surgeon ‘shaving time off each case’
Across the various Melbourne surgical facilities Dr Clearly performs ophthalmic surgery in, she’s had access to a ZEISS OPMI LUMERA 700. It’s been a workhorse microscope over the years; one she describes as the industry standard – up until this point.
But she’s somewhat disappointed to go back to her old microscope after trialling the ZEISS technology poised to supersede it, the ARTEVO 750.
She spoke to Insight following two cataract lists at Cabrini Brighton with the new microscope, where she was struck by several improvements around patient safety, pre- and intra-operative surgical efficiency, and the upgrade to the CALLISTO eye 5.0 system that acts as the surgeon’s “intuitive cockpit” alongside the microscope.
She’s also excited about the potential of greater visualisation in her corneal transplant work. This is on top of all the other hallmarks of ZEISS microscopy such as reliability, image quality and digital integration with instrumentation, such as the IOLMaster 700 biometer, used in the work-up phase.
Among the new features, ZEISS is promoting the RGB LED illumination function (also available on the ARTEVO 850) that allows ophthalmologists to select different light colour temperatures according to their preferences. A mix of red, green and blue LEDs generate different light color temperatures, from cold to warm.
There’s also AdVision, a system that overlays surgery data into the eyepiece at a 40% higher resolution and high contrast. The surgeon can select from a wide range of cataract assistance functions, phaco parameters or iOCT.
“It was very customisable; for example, we played with the capsulorrhexis overlay and I found I liked a yellow circle that wasn’t bold, so that it didn’t interfere with the task at hand,” Dr Cleary, who’s also head of the Surgical Ophthalmology Unit at the Royal Victorian Eye and Ear Hospital, says.
“But additionally, there’s lots of useful content that one can see in this heads-up display. It included patient details, the intended toric axis, whether the recording is on or off, and the colour temperature in use. This data is located peripherally in the digital overlay, which is great because it doesn’t distract you while operating.
“But even just having the patient’s name and details in there is a constant reminder that we have the correct patient in front of us at all times.”
In fact, Dr Cleary says there are other ARTEVO 750 features that enhance patient safety, largely thanks to graphical interface improvements ZEISS has made to CALLISTO eye.
Integrating the microscope with this system gives surgeons like Dr Cleary a centralised point of control. It might sound simple, but an example of this is the new patient summary page. When the theatre team take their ‘time out’ prior to each case, it allows them to easily confirm what’s on the operating table aligns with the surgical plan.
“It’s all presented on a nice layout and now there’s a diagram that shows us the toric alignment which was not present on the previous iteration. It’s excellent for patient safety; this page didn’t exist to the same degree in the previous model.”
She’s also noticed much speedier patient data upload into the microscope, creating new efficiencies for theatre staff, and fewer steps.
Digital toric alignment is a key application of CALLISTO eye in the cataract surgery workflow. This requires the microscope to match an intraoperative image of the eye with a pre-operative scleral image obtained on the IOLMaster 700.
“The other big thing: when we match the intraoperative image with the pre-op scan, this is super quick, much faster than the previous model.
“Together, these improvements all shave time off each case.”
Dr Cleary says ophthalmologists make the common mistake of associating CALLISTO with markerless toric alignment only. But in reality it can perform other tasks such as sizing of the capsulorrhexis or pinpointing the incision placement.
In the latest update, these cataract assistance functions can be completely surgeon-controlled with a push of a button on either the foot control panel or handgrips.
During her first surgical lists with the ARTEVO 750, Dr Cleary briefly used the iOCT function that she expects will reap benefits in corneal transplant work too.
“The iOCT image was definitely enhanced from the previous Rescan, and also captured images and zipped to the correct focal plane incredibly quickly,” she says.
“Previously, the ambient lighting of the operating theatre could make it difficult to see the image on the screen clearly, but this was much sharper and offered greater contrast.”
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