Digitalising the OR—Experience and Perspectives

Digitalising the OR saves time and may lead to more precise outcomes, effectively improving the refractive cataract surgery experience for both the surgeon and the patient, agreed presenters at a session at the 2024 ESCRS Winter Meeting in Frankfurt.

“Most of the time we spend on surgery is not on the surgery itself, but on the pre- and postoperative care,” Professor Dr Wolfgang J Mayer said. “Patient information, lens power calculation, and lens ordering are just some of the limitations preventing a smooth streamline of workflow in cataract surgery.”

“While doing a small literature search, I was surprised to find out how little is written about digitalisation,” Kjell Gunnar Gundersen MD, PhD, told the audience during his presentation. “There are definitely some obstacles or things to pass, especially being forced into some EHR systems, which are not very nice to integrate into the ophthalmological practice.”

Improving the set-up

Prof Dr Mayer contended that despite the barriers potentially preventing digital OR adoption, there is a sensible return in saving time.

“We have transformed our university clinic in Munich into a digital OR, fully digitalising a previously paper-based workflow and connecting every device from diagnostics to surgery,” he said. “So, we save up to six minutes per surgery in the OR, as well as four minutes per patient in the diagnostics, just by doing it completely digitally.”

In his practice, Dr Gundersen opted for a platform that can integrate different instruments from different providers. “I have all the preoperative biometry, transcriptions, and planning needed. During surgery, we have markings, cyclotorsion, rhexis, and positioning, and postoperatively, we can analyse our results and fine tune it for our next patients.”

Since at least 40% of patients will profit from toric IOLs, measuring corneal astigmatism is crucial for the good outcomes of cataract surgery.

“When we look at diagnostics, we have to look for solutions that can help us in making powerful measurements of corneal astigmatism, taking the exact data and value and comparing different formulas to get the right lens selected, and using an OCT for the posterior segment to avert possible macular or retinal conditions,” he added.

“This is the digital cataract procedure, where we can go ahead with our measurements and put our power calculation on any workstation—with no fear of transcription errors—because the data is provided directly from the network.”

There are many systems on the market for a tridimensional approach, focusing on improving depth perception and a more ergonomic surgical position, as well as an enhanced view for the entire surgical team.

Sharing personal experience

“In the examination room, we have access to information from biometry, optometry, digital photography, and OCT,” Dr Gundersen said. “When we have all this information, we can have a proper discussion with the patient to decide how to [proceed]. From [there], we go directly to the biometry room, which is the heart of cataract activity. We can use different biometries and plan surgery based on those examinations. We then export the information into the surgical room, ready for surgery.”

All the information is exported to workstations beside the surgical microscope, where the surgeon can access patient data, IOL information, and the video overlay of the toric axis on the screen. At the end of the procedure, the surgeon can fine-tune the axis based on the information on the video overlay.

Prof Dr Mayer reported that one of the first studies he did with the Callisto Eye System and Forum Viewer (Zeiss) compared the digital approach of toric lens alignment to the manual approach. He found it much safer and more efficient in correcting corneal astigmatism, also saving six minutes every time.

“During the implantation of a toric IOL we can see the steep axis of the cornea, which we have also calculated together during the power calculations with the EQ Workplace. And now, the Zeiss Callisto helps me track and align the toric lens, so it will always be on focus,” he explained, adding a digital workflow provides a complete solution, from software-based planning to surgery.

“We have all the data digitally and can provide this after a good and precise calculation within the software on any workstation in the OR, and maybe select another lens thanks to the real-time assessment—that is the most powerful tool we have with this kind of solution.”

“It is a nice way of transferring biometric data from the examination room to the surgical room, and thereby improving our results,” Dr Gundersen concluded. “At the end of surgery, a happy patient can walk out of the surgical room.”

Wolfgang J Mayer FEBO is Deputy Director of the University Eye Hospital, Munich, Germany. wolfgang.j.mayer@med.lmu.de

Kjell Gunnar Gundersen MD, PhD is a practising ophthalmologist in Haugesund, Norway. KGg@Ifocus.no