Q&A: Artevo 850 microscope offers surgical precision, improved view, more comfort

Key takeaways:

• Intraoperative OCT with the Artevo 850 can be beneficial in challenging cases.
• 3D visualization technology can aid in surgical performance.

Intraoperative OCT and 3D visualization are innovative approaches aimed at enhancing the quality of surgical performance.

Neither technology is new, and it has taken years to overcome initial drawbacks and limitations to become the reliable systems of today.

In this interview with Healio, Aude Couturier, MD, PhD, a retina specialist at Hôpital Lariboisière and Hôpital Fondation Adolphe de Rothschild in Paris, shares her experience with and thoughts about the Artevo 850 microscope (Zeiss) with integrated intraoperative OCT (iOCT) and advanced 3D digital visualization.

Healio: Please tell us about your experience with the Artevo intraoperative OCT technology. What are its advantages, and what are the cases in which you would recommend the use of OCT-assisted surgery?

Couturier: I have been using the newer Artevo 850 recently, but I used to work with the previous models of Artevo. The most important feature of this microscope is the high quality of vision, as well as the presence of intraoperative OCT, which is useful in many challenging cases. With my group at Hôpital Lariboisière, we published some years ago a retrospective series of highly myopic eyes that underwent vitreomacular surgery with iOCT for epiretinal membrane, macular hole and myopic foveoschisis. We showed that in almost 10% of the cases, intraoperative OCT allows us to see some macular or peripheral retinal breaks that we cannot detect with the standard intraoperative view. Highly myopic eyes are also at a higher risk of developing a full-thickness macular hole after surgery, and it is therefore useful to be able to check the fovea at the end of the peeling. This also helps us decide on our intraoperative tamponade.

Today, I cannot consider operating on highly myopic eyes without iOCT, and there are many other challenging surgeries in which it is useful, such as patients with diabetes in whom intraretinal hemorrhages are frequent and when we don’t know about the status of the macula before the surgery. It is also useful in cases with tractional retinal detachment in which we do some segmentation and removal of the proliferation. It is important to check the fovea at the end of the procedure. Intraoperative OCT allows a controlled approach to subretinal tissue plasminogen activator injection for subretinal hemorrhage, and in the future, once we have gene therapy for our patients with age-related macular degeneration, we will be able to monitor delivery of the treatment intraoperatively. With the Artevo 850, the resolution of intraoperative OCT is high and comparable to what we have on preoperative OCT.

Healio: The Artevo system also allows for 3D visualization of the operating field. What are the advantages of this?

Couturier: 3D viewing is an important tool for vitreoretinal surgeons. The resolution and magnification of the intraoperative view are amazing, and depth of focus is enhanced. We are able to get a detailed view of the macular anatomy for internal limiting membrane (ILM) peeling and when we want to peel the epiretinal proliferation associated with lamellar macular hole. There are also some filters that can be used to have a better visualization of the vitreous or a blue visualization of the ILM. Just like iOCT, and together with iOCT, 3D viewing takes us far beyond what we can see with our conventional microscopes. In an educational setting, 3D is also useful because you can help students to improve their surgical skills. You have exactly the same view that they have and can guide them with more precision.

Healio: How does intraoperative OCT combine with 3D visualization?

Couturier: With 3D, you have a large view on the screen. You can have the intraoperative OCT running at the same time during the entire procedure and see in real time what you are doing without disturbing your intraoperative view, as it used to be when OCT was incorporated in conventional microscopes.

Healio: What about the ergonomics of heads-up surgery? Is this an advantage?

Couturier: It certainly is. We always think about the comfort of the patient first, but the comfort of the surgeon is also important for high-quality surgery, especially when you deal with challenging cases that require longer procedures. And in the long term over the lifespan of a surgeon, better ergonomics and more comfort can avoid the backaches or neckaches that have been reported to be so frequent among vitreoretinal specialists. I feel more comfortable when I do the surgery myself and when I help my students. I sit next to them, and instead of bending my neck as I was doing with a conventional microscope, now I can be as comfortable as if I were watching TV.

Healio: Is the technology for 3D surgery mature enough for a wider uptake?

Couturier: The technology has evolved and remarkably improved. It used to be a little slow, the depth of focus was not so high, and surgeons at first did not notice a big difference from the conventional microscope. They also needed to adapt to the delay between what they were doing and what they were seeing. But now these delays are virtual. I cannot see any difference. I tested heads-up 3D surgery maybe 5 or 6 years ago, and I was not convinced. But when I recently tried the 3D of the Artevo, I noticed the difference and improvement of the technology. I felt that I definitely wanted to embrace this way of performing surgery. If you have experience as a vitreoretinal surgeon, it is easy and fast to adapt to this new technology, and there is no learning curve. Even my residents feel comfortable after only one or two surgeries.

Healio: Is 3D OCT-guided surgery going to be the future?

Couturier: Definitely. The enhanced resolution, expanded view, comfort, and more direct and efficacious approach to learning will allow us to improve our techniques and make surgery more precise, safer and better. Now that I am using 3D and iOCT for all my surgery, I would never go back to a conventional microscope.

Reference:

• Bruyère E, et al. Retina. 2018;doi:10.1097/IAE.0000000000001827.

For more information:

Aude Couturier, MD, PhD, can be reached at aude.couturier@aphp.fr or acouturier@for.paris.

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