Technology plays an integral role in retina surgery. While the surgeon’s learned and practiced skill set is paramount for ensuring the desired outcome, the ability to manipulate and dissect delicate tissue during surgery would not be possible without the instruments we hold in our hands, the microscopes (or displays) we use to view the surgery, and the array of lighting options that illuminate our field of view.
To the great benefit of patients, the spirit of innovation that has provided the current array of surgical technologies continually delivers new and interesting products and devices that offer to impact a dimension of surgery, thereby improving safety, efficiency, and outcomes. However, surgeons tend to be creatures of habit—and for very good reason: adding something new to the mix could disrupt the delicate balance of surgery, potentially putting the patient at risk for a bad outcome, or worse, affecting safety.
How can surgeons decide whether a new piece of technology might improve their experience in the OR and benefit patients’ safety and outcomes, or whether it will be an impediment to achieving the desired objectives of a surgery?
Evolutionary Versus Revolutionary Innovations
There is a difference between innovations that require a modification to an existing technique or maneuver and those that compel the surgeon to do something entirely novel. New technologies can be broadly understood as evolutionary or revolutionary.
In medicine and in surgery, most of what we tend to deal with is evolutionary in nature (Figure 1). From a strictly clinical perspective, perhaps the most important question we might ask about a new device or technology is whether it will improve some aspect of surgery. For example:
- Does it make the surgery safer for patients?
- Is it more efficient for the surgeon?
- Does it have potential to improve outcomes?
Figure 1. Evolutions in surgical technology take many forms, yet they should all fundamentally improve some parameter of surgery to justify implementation into one’s surgical routine.
The interaction of these variables is dynamic. Operating in a shorter amount of time is more efficient, but also may affect safety, if the surgeon is in the eye for less time. Using instruments that can perform more than one task adds to efficiency, but may also introduce new ways of performing maneuvers that may be safer or more advantageous to the outcome.
A stepwise progression in implementing technology is logical, as it has less potential to upset the balance of safety, efficiency, and outcomes. Jumping from using 20- to 27-gauge instrumentation, for instance, might be too big a leap, whereas gradually moving from 20- to 23-gauge to 25+ before trying 27+, and taking time at each step to get accustomed to the differences, might make more sense. A more tangible example of an evolutionary change is the recent introduction of the FINESSE SHARKSKIN ILM Forceps (Alcon). While there are a plethora of forceps options, the larger platform and the addition of a serrated edge on these forceps improve the ability to gain an edge on a tissue plane. Because these features positively impact an aspect of surgery, and the instrument does not require the surgeon to relearn the fundamentals of a membrane peel, adding the FINESSE SHARKSKIN ILM Forceps in place of a favored set of forceps is not a tremendous leap of faith.
The Practice Perspective
Elias C. Mavrofrides, MD
Framing the evaluation of new technologies in terms of evolutionary versus revolutionary technologies also has applicability from a practice management perspective. Iterative or evolutionary improvements in surgical technology often have a lower barrier for implementation. They are not significantly changing the practice, and if the accounting makes sense, they should not add significant expense. If the new device or technology is going to help our surgeons perform better in the OR—and there are innumerable metrics with which to gauge that effect—and if it is associated with a modest investment, the evaluation is more straightforward. Other types of innovations are more revolutionary, requiring a significant investment, a big change to our surgeons’ protocols, or both. And if that is the case, justifying the expenditure becomes a little more complicated.
Evolutionary changes in technology are not always mundane, and they may have impact beyond the obvious. I have recently been given the opportunity to try out the HYPERVIT Dual Blade Vitrectomy probe (Alcon) in some of my surgeries. The faster cutting speed (up to 20,000 cpm) is the most notable upgrade with the HYPERVIT, but the true engineering breakthrough is the dual blade cutter and bias-open port, with the latter making it possible to have an almost 100% duty cycle. Additionally, the beveled tip is useful for getting under a tissue plane and dissecting at the same time. These features offer to improve efficiency and provide conditions for better safety, making the HYPERVIT a logical addition. Above and beyond that, I have found that HYPERVIT solves some of the inefficiencies inherent to small-gauge surgery, to the extent that I am considering whether I should adopt more 27+ into my practice. Time will tell, but getting more comfortable with smaller gauge surgery, with all its potential to improve safety and outcomes for patients, may be yet another way HYPERVIT will help improve my surgeries.
Disruptive Technology: When to Cross the Chasm
While the large swath of innovations offered into retina practice are iterative, occasionally an idea comes along that is so intriguing and provocative that it demands attention. I would count the NGENUITY 3D Visualization System (Alcon) as one such revolutionary device (Figure 2). Although it requires learning an entirely new way of looking at surgery, the potential tangible and intangible benefits NGENUITY offers help to justify the investment in navigating the minimal learning curve.
Figure 2. Despite that NGENUITY requires the surgeon to learn a completely new way of viewing surgery, the associated benefits help justify the investment in the minimal learning curve.
Some of the same questions asked about evolutionary surgical products also pertain to those technologies considered revolutionary. Additionally, it may be necessary to think about whether the initial idea can be expanded or built upon. The latter is not necessarily a prerequisite for adoption but may add compelling rationale for going outside one’s comfort zone.
The landmark book, Crossing the Chasm by Geoffrey A. Moore,1 offers a useful framework for understanding how disruptive technologies become the new status quo. It does an excellent job in explaining how divergent expectations create a metaphorical chasm between early adopters of new technology and what are labeled the early majority, the pragmatists who resist disruptive change, at least initially. The fundamental question throughout is what will it take to convert the early majority?
The answers to those questions are highly personal and likely multifactorial. For our practice, and using NGENUITY as an example, what drove us to be early adopters around 2 years ago was not necessarily what we thought the platform would do at that time, but really what we believed its potential could be in the future. The move from analog to digital viewing was impressive on its own; and yet, the greater ability for detailed viewing was almost secondary to the realm of possibility opened by using a digital viewing system. Since adoption, we have recognized many benefits with NGENUITY, some that we anticipated and others we learned more about after we started using it in surgery (please see the digital sidebar, “Unexpected Benefits With Digital Surgical Viewing During COVID-19”). We knew from the onset that NGENUITY offered to improve both depth of focus and depth of field compared to microscope, but we did not fully realize that a digital image can be manipulated in ways that analog images cannot. For example, adding color filters might improve visualization. As well, digital viewing systems use lower light levels compared to ocular viewing, which potentially reduces the risk for phototoxicity while increasing working time inside the eye.
Our practice’s willingness to adopt HYPERVIT was actually predicated on similar thinking: it would improve performance in the OR without requiring a rethink to normal workflow. It became apparent that at least trying it would be a low-risk/potentially high-reward proposition. In the past, we have used a similar framework when evaluating valved cannulas and lighted lasers, examples of technologies that don’t significantly disrupt workflow, but do improve conditions in the OR.
Like most practices, when it comes to revolutionary technologies, we weigh the benefit against the cost, which remains a real challenge and an important question to ask of any new technology being considered for implementation. With technology used in surgery, there is often not the promise of additional billing. Most often, they are making your work better in the OR, and so some of the intangible factors become emphasized in decision-making. For instance, we may be able to make a case for increased volume, if surgical time will go down. Perhaps our surgeons can expand their services using the new technology. The bottom line is that the capital expenditure for new technology may be the most important factor clinics might consider, but it shouldn’t be the only thing.
At the same time, upgrading a practice’s technology is always somewhat of an unknown, as the true effect is not fully known until it is implemented into regular use. We have to use our best prognostic powers to determine what we expect the impact to be, but we always have to be prepared for the unexpected. When we are presented with new technology for use in retina surgery, the evolutionary changes we implement require the same careful scrutiny as the revolutionary ones. With the latter, though, there is an additional challenge in justifying what is often a larger capital investment when confronted with ever-present reimbursement challenges facing our subspecialty and all of medicine (not to mention the investments of time and resources).
In our assessment, we determined that the various features of NGENUITY were additive, complementary, and synergistic in improving surgical viewing compared to microscope. That said, we may only be scratching the surface with this technology when we think about how concepts like AI and augmented reality might be layered in.
The Value Proposition
Thinking about how much a novel innovation may improve a surgical variable and what benefit(s) it may provide are helpful for determining if it is worth exploring. Assessing whether the product adds or is associated with some additional value could help tip the balance on whether it is worth implementing.
What else did our practice consider while evaluating NGENUITY? In fact, several intangible factors helped us make the leap:
1. Good medicine is good business. Our best marketing is being the best clinicians that we can be; this mindset results in always striving for better patient care, which is really what we are about as a medical practice. If we are presented with a technology that offers to improve our chances of doing that, it is something we can consider on the ‘pros’ side of the equation, even if the investment is substantial.
2. Training. One of the well-known benefits of NGENUITY is in how it enhances surgical training. For a private practice group like ours, this may seem less important than it would be compared to academic centers. And yet, we can use NGENUITY as an instrument to educate and teach local community ophthalmologists and optometrists about what we do in the OR. In our network, we still encounter a fair bit of stigma around vitrectomy and a belief that it is still extremely invasive or a last resort option for sick eyes. We have started to make inroads to dispelling these myths using some of the training features traditionally associated with NGENUITY.
3. Ergonomics. We recognized that digital viewing puts our surgeons in a more comfortable and stable position compared to the oculars. Protecting our surgeons with improved posture and ergonomics provides for a more enjoyable surgical day, and I feel it could possibly help them practice surgery for many years longer. There is a huge financial benefit to protecting the health of our physicians.
4. Expansion potential. Getting involved early would give our surgeons the opportunity to participate in the platform’s continued development and to become truly expert in using what we believe will become the surgical platform of tomorrow.
In some respects, our practice was not among the earliest of adopters of NGENUITY. The ‘wow factor’ was evident, but we did not initially accept all of the intangible benefits. To Alcon’s credit, the company continued to develop the technology, making it better at each stage, and representatives kept showing us its potential. Over time, we came to see how it would change the experience in the OR for patients, surgeons, and staff. The many intangible and value-added aspects of NGENUITY soon became obvious to us and have since been realized after adoption.
Value can be defined in a multitude of ways. The idea that HYPERVIT might make 27+ surgery a more viable consideration could be perceived as an added value. The SHARKSKIN forceps are a low-dollar investment that easily replaces existing forceps, but because they do the same job a little more efficiently, they have higher comparative value. In our experience, NGENUITY has been a valuable addition to our practice, helping to improve visualization, engage the entire OR staff in the surgery, and expand upon our surgeons’ skill sets without causing any disharmony in our operations.
Another way to define the added value of a given technology is in how it is supported—what else do you get when you make a purchasing decision? In my experience, a couple of things really stand out from working closely with Alcon. The relationships I have developed with its representatives have been invaluable for training on new technology and troubleshooting when something goes wrong during a case. Those relationships extend to the caliber of surgeons who work and interact regularly with Alcon. The products Alcon produces are thoughtfully engineered and designed, but the company also readily accepts feedback to make sure they are responsive to surgeons’ needs. Some of the best surgeons in the world have been intimately involved in improving Alcon’s portfolio of offerings. That is both reassuring and a valuable resource to learn from.
It is important to us that any new technology added to the OR be fully supported, from onboarding through implementation as well as into the future. And so, that NGENUITY was backed by one of the industry stander bearers was very important in our thinking process. In thinking about intangibles, confidence in the company developing the technology is of utmost importance, because the bigger the investment, the bigger the expectation on the company you partner with.
Just as a surgeon’s particular techniques and approaches are learned and personal, so too is the framework each surgeon uses in deciding on and implementing new technology. Each surgeon has to determine his or her comfort level on new technologies because ultimately the patient’s best interests and safety and outcomes have to take precedence. Regardless of whether a new technology is evolutionary or revolutionary, using it in the OR is likely going to feel different, and so careful thought has to be given to how it is implemented.
In assessing one’s own comfort level, however, it is also worth keeping in mind that all of the various instruments and technologies used in retina surgery were at one time considered novel. Keeping an open mind to change is important, so as to continually improve upon safety, surgical efficiency, and outcomes for patients. Lastly, when considering a new instrument or device, it may be prudent to determine whether there is some additional value in partnering with the company behind the product.
1. Moore GA. Crossing the chasm: marketing and selling technology products to mainstream customers. New York, N.Y.: Harper Business, 1991. Print.
Participants are paid consultants of Alcon.
© Alcon Inc. 8/20 US-SG-2000136