GUEST EDITORIAL

Intraoperative Video: A Powerful Tool to Improve Outcomes in Vitreoretinal Surgery

JOHN D. PITCHER, III, MD

Professional athletes spend many hours each week in the “film room.” The process of analyzing footage from the previous game is a critical part of training and player development. Football teams invest heavily in technology and personnel devoted to scrutinizing each play from more than 20 different camera angles.

On the sidelines every fall weekend, you can bet on seeing the quarterback and his position coach reviewing aerial shots from the preceding drive — ensuring that mistakes in technique or execution are not repeated.

Similarly, pro golfers constantly analyze and revise intricate details of their form with a swing coach, making adjustments of just a fraction of an inch to help shave scores by a shot or two.

Amateur athletes can benefit from similar training methods. In college, my tennis coach would record all of our practices and matches. He would play back hundreds of our shots: forehands, backhands, serves, and volleys. At the time, the painful review process seemed like overkill, but it became clear that it translated into individual improvements and, ultimately, team wins.

These days, even “weekend warriors” can walk into almost any golf pro shop and receive a video-assisted, customized swing breakdown. If we spend this much time and money on a hobby, why not apply the same principles to our profession?

THE PRO OPHTHALMOLOGIST

The analogy between athletic and surgical performance is an easy one to make. As retina specialists, we have high standards for ourselves, from our patients, and, increasingly, from payers such as CMS. In the coming years, registries and electronic health records will allow anatomic and visual outcomes to be under the microscope — no pun intended.

This pressure coincides with an era in which vitreoretinal surgeons are spending less and less time in the operating room, and medical, office-based treatments are replacing more invasive therapeutic options. Fewer cases amount to fewer opportunities to maintain technical proficiency, especially in less commonly performed procedures.

Academic medical centers have recognized the challenges of developing naïve medical students into competent surgeons. This has increased in the era of minimally invasive and laparoscopic surgery.

Ophthalmology residency program directors, in particular, appreciate the value of using technology, such as virtual reality platforms and video recordings. Some of these methods have been validated to improve proficiency.¹

Phacoemulsification — ie, cataract extraction — is a fairly standardized procedure that lends itself to a systematic approach to measuring and documenting learner progression. Recording trainee cases allows for deliberate review — an opportunity to improve surgical efficiency and patient safety. This process is much more constructive than watching expert surgeons performing five-minute cases.

At Wilmer Eye Institute at Johns Hopkins, for example, instructors created a library of “less than perfect” examples of each step of the procedure — from eye draping to intraoperative lens insertion — to create a more realistic picture of what beginners can expect on their first cases.

In the two-year training program at Wills Eye Hospital, retina fellows perform an average of 1,200 vitreoretinal surgical procedures. On the first day, we were provided with a more than 2-TB external solid-state hard drive so that all cases could be recorded.

There are many benefits to having footage of every surgery. At the end of each OR day, I would have an “instant replay” session, during which I would review portions of each procedure.

Early on, the focus was on basic steps, such as sclerotomy creation or trocar removal. Toward the end of my fellowship, I would routinely review each video to evaluate proficiency in complex cases, such as challenging membrane peels (see Video, below). Each month, the senior fellows moderated a surgical conference, which was always very well attended by faculty and members of the community.

VIDEO ON DEMAND

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Download the free Actable interactive print app from the app store (available for both iOS and Android devices)

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Launch the app and scan this entire page

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Your video will begin

Now that I am in full-time practice (and no longer operating five days per week), I use this accumulated digital catalogue as a resource before setting foot in the OR. In particular, if I have a “less routine” procedure on the schedule — scleral suturing of IOLs, subretinal tissue plasminogen activator injection, chorioretinal biopsy, silicone oil retention sutures, etc. — I will take the time to watch relevant surgical techniques.

To use another analogy from the world of professional athletes, this serves as a “mental rehearsal,” a fundamental principle of sports psychology. This simple process improves efficiency and confidence, which can facilitate better outcomes.

IN YOUR PRACTICE

There are several other ways in which surgical recordings can be used to enhance your practice. Consider adding a monthly or quarterly case conference with the partners in your group. This setting provides a low-pressure environment for “real-world” discussion.

If you have a particularly interesting video, submit it for presentation at an annual meeting, an online video resource site, or even a peer-reviewed journal. In addition to benefitting your colleagues, the exposure gained from multimedia presentations can extend to patients and even referring ophthalmologists and optometrists.

Finally, edited and narrated routine cases can be used for patient educational purposes. Similar to those used by cataract and refractive surgeons, vitreoretinal procedure videos viewed preoperatively can help to answer patient questions and set appropriate expectations.

Most microscope-mounted cameras are well suited for capturing anterior-segment and ocular surface work, primarily because of the ample light supplied by a source external to the eye.

It is more difficult to illuminate the posterior segment. Recording quality is ultimately governed by brightness — whether a beam-splitter is employed, whether a cataract or IOL is present (images from aphakic eyes are brightest), which viewing system is used (contact lenses lose less light than noncontact systems), and the specifications of the camera.

CUTTING-EDGE SOLUTIONS

Many of the newer surgical microscopes include integrated video solutions. Built-in camera systems with factory-aligned optics allow for streamlined recording without bulky cables or adapters.

Some models, such as the Carl Zeiss Meditec (Dublin, CA) OPMI Lumera i, feature automatic adjustment of settings when switching between anterior- and posterior-segment surgery.

If your surgery center or hospital does not currently have a camera, there are a few options short of buying a new microscope. Optronics (East Muskogee, OK) offers beam splitters, adapters, and high-definition cameras compatible with most major scope brands.

Expensive vendor-sold, preassembled recording systems are not necessary to obtain digital files. Compressed video can be generated using a portable H.264 Pro Recorder (Blackmagic Design, Fremont, CA), which can be purchased online for a small investment of approximately $500. This is connected to the camera with a standard HDMI cable. It will transmit directly onto a laptop via USB 3.0 connection.

AUGMENTED REALITY

Augmented reality interfacing with intraoperative OCT is the next big thing in vitreoretinal surgery. Next-generation microscope cameras will have the capability to record these data superimposed on surgical video. Three-dimensional visualization also promises to be incorporated into many new systems.

The future of intraoperative recording is bright. As technology continues to make it easier and more affordable, we can use this digital tool to refine our skills and, ultimately, improve patient outcomes. RP

REFERENCE