Wide-angle non-contact visualisation changed the game for vitreoretinal surgeons globally. Two surgeons discuss how two manufacturer-agnostic innovations from OCULUS have set new standards
in their highly complex work.
Knowing what he knows now, Dr Kazuhito Yoneda reflects in quiet amazement on how retinal surgeries were performed early in his career. A prism or indirect viewing contact lenses – held steady by hand – provided the portal into the delicate, high-stakes world of his vitreoretinal procedures.
At the time, this was the norm. But even then, the limitations were obvious.
“When I started out using prism lenses, this was a very narrow viewing system. We then moved to other contact lens systems, which offered an improved field of view but because it needed to be held steady by hand, it was challenging when I needed to operate bimanually with both hands,” he says.
“If I wasn’t holding it myself, I had to depend on an assistant to hold it steady, however that wasn’t always reliable and it was difficult to achieve consistent visualisation.”
Stereopsis reduction, fogging and smudging are other issues that could cause interruptions for Dr Yoneda. Eventually, other visualisation technology came but fell out of favour due to its bulkiness, obstructed surgical view, or low image quality.
It was the complexity of vitreoretinal surgery that first attracted Dr Yoneda to the subspecialty more than 25 years ago. But ironically, it wasn’t until he encountered technology from German ophthalmic device manufacturer OCULUS that he fully realised just how limiting his earlier tools had been – particularly in tackling challenging cases like giant retinal tears, proliferative diabetic retinopathy (PDR), and proliferative vitreoretinopathy (PVR).
That realisation occurred 10 years ago, and still rings true today.
The OCULUS’ BIOM 5 wide-angle non-contact viewing system, used in conjunction with the company’s WiFi (wide-field) HD lens, is the linchpin in his vitreoretinal surgery setup at Sakura Eye Clinic group and Subarukai Eye Center.
It’s all seamlessly integrated with his Leica Proveo 8 microscope, including its inverter to correctly orientate the surgeon’s view, with the surgery then displayed on his Alcon NGENUITY 3D heads-up system.
Three components from three manufacturers working harmoniously.
When it arrived in 1985, OCULUS says its BIOM technology altered the vitreoretinal landscape, reshaping fundus viewing by continuously incorporating the principle of indirect ophthalmoscopy in the operating microscope. It allowed more surgeons to branch out into the field.
Crucially, the BIOM 5 is aligned coaxially with the operating microscope, and during extraocular phases of surgery it is swung out of the observation beam while the inverting action of the OCULUS SDI inverter is neutralised.
Surgeons can then pair the BIOM 5 with various lens types, with the most popular being the WiFi HD lens – also known as the gold lens – offering high resolution and a wide field of view across 60-130 degrees.
Combined, the system has been developed for precisely the type of cases Dr Yoneda manages. He describes its integration with the Leica Proveo 8 microscope as “streamlined and intuitive”, enabling synchronised focusing via the microscope’s native foot pedal – a feature he now considers indispensable.
“During extraocular phases of surgery the built-in inverter of the Proveo 8 integrates seamlessly with the BIOM 5,” he says.
“The swing-out function operates smoothly and naturally, and the synchronised focusing system operated by the native foot pedal allows effortless focus adjustment, enhancing surgical flow without disrupting the procedure.”
Dr Yoneda also highlights the physical improvements the system has brought to his work. Performing five to 10 retinal surgeries during each operating session can leave him physically strained, but the efficiencies brought about by BIOM 5 paired with the NGENUITY 3D display system has significantly improved ergonomics in the operating theatre.
“This has helped reduce fatigue and improved my concentration,” he says.
But the core value, he says, lies in the image quality and field of view.
Using the WiFi HD lens on the BIOM 5, the system offers a wide viewing angle allowing him to visualise both the macula and far periphery without the need to switch lens types.
“I can use the WiFi HD lens in every case,” says Dr Yoneda, who opts for the disposable version of this lens with advantages in sterility, reduced contamination risk, and consistent optical clarity – even though the reusable WiFi HD lens is the most commonly selected option among surgeons.
“It gives me the confidence to tackle complex conditions without interruption. Retinal detachments, PDR and PVR can have peripheral and posterior elements to address at the same time. But when I use the WiFi HD lens, we can see a very clear peripheral view and, at the same time, very clear macular view.”
Smooth surgical manoeuvres
In PDR cases, this is where fellow Japanese surgeon Dr Shunsuke Osawa agrees the BIOM 5 and WiFi HD lens stand out.
He uses an identical setup to Dr Yoneda, the only difference being the use of a contact lens to protect the cornea and maintain a smooth corneal surface (this lens is not for magnification). For macular work, with the WiFi HD and BIOM 5 system, he uses the zoom function of the microscope to achieve a 60-degree macular view without the need to switch to a separate 60-degree lens. He recommends a 60-edegree lens when a more stereoscopic view is required.
“In PDR, it allows me to perform a posterior vitreous detachment as far out as the equator, and then accurately visualise and dissect proliferative membranes near the vascular arcades using the 60D lens under excellent stereopsis,” he says, performing surgeries at MIE Eye Clinic.
“In cases of giant retinal tears, retinal slippage during reattachment is a major concern. The seamless operability of the BIOM 5 allows for smooth surgical manoeuvres, while the excellent clarity provided by the WiFi HD lens ensures precise subretinal fluid drainage, helping to prevent retinal slippage.”
A change-agent
In many ways, OCULUS’ contributions helped open up the field of vitreoretinal surgery.
That’s according to regional director for Asia, Mr Richard White, who says the company’s journey into the subspecialty began when Mr Rainer Kirchhübel – CEO of the OCULUS family enterprise since 1981 – began working with surgeons to develop the SDI inverter.
“In the beginning, very few surgeons in any country were doing vitreoretinal surgery,” he explains. “It was difficult – hand-eye coordination was hard, and it was tough to truly visualise the posterior segment.”
The original SDI inverter system helped orientate the surgeon’s hand movements with what they would expect to see. In other words, when their hand goes up, it also goes up through their oculars.
“Innovations like this helped to increase the number of retinal surgeons 10-15 fold,” White says.
“And with more great surgeons being able to see and understand the problems at a deeper level, they wanted to start exploring more surgical capabilities. They asked, ‘right now we’re only concentrating on 30 degrees with a contact lens, but what about if we can start doing surgery more in the peripheral areas of the eye?’.”
Working closely with German surgeon Prof Manfred Spitznas, OCULUS developed the BIOM system.
“It really revolutionised the retinal subspecialty,” White says. “The SDI let more people get involved. The BIOM helped them do more surgeries and treat more patients.”
Asked what continues to keep OCULUS at the forefront of this field, White says all roads lead to the company’s rich heritage in optics. The multi-lens trial frame – which overcame complicated wavefront issues and distortions brought about by stacking of lenses – is an example of its grounding in optics.
White also believes OCULUS’s smaller size enables a nimble, collaborative approach to innovation. “We’re just over 500 people globally. If a surgeon has an idea, it can reach our CEO in a day, depending on the strength of the idea. That direct connection with the field helps us stay aligned with what surgeons really need.”
The WiFi HD lens is a case in point, overcoming the need to switch out lenses during retina surgery.
“It allows the surgeon to see from 60 to 130 degrees – and everything in between, which all comes into focus with just the foot pedal,” White explains.
“That’s unique to us – all other lens options are set-degree. Around 95% of our retinal lens orders are for this lens.”
Compatibility and workflow flexibility are also key. The BIOM system can be adapted to fit virtually any microscope on the market, partnering with at least eight of the biggest names in ophthalmic manufacturing.
Plus, with growing interest in disposable products, OCULUS offers single-use options for emergency use or infection control, particularly valuable when sterilisation delays are impractical or when there’s a blood pathogen concern like HIV.
“With really solid IP, coupled with a grassroots connection to the industry,” White adds, “we’re able to keep on top of what the industry wants and needs and set the future direction in this space.”
Reflecting on how those needs have evolved, Dr Yoneda sees the BIOM 5 and WiFi HD lens not only as an upgrade, but a shift in how he approaches retinal surgery.
“It’s changed how I work. I’m faster, more comfortable, and more confident. Most importantly, I can perform some of the most difficult cases in ophthalmology and give my patients the best treatment and the best chance of recovery,” he says.
For Dr Osawa, the most impressive features of the BIOM 5 system are its high image resolution – even during fluid-air exchange – widefield angle view, compatibility with the Proveo 8 microscope, and integration with his Alcon NGENUITY 3D heads-up display.
“Above all, the BIOM 5 enables high-resolution, panoramic visualisation of the entire globe, which contributes to safer and more efficient surgeries across all cases,” he says, “especially those that are complex or delicate.”
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