Smartphone Augmented En-Face Guided Epiretinal Membrane Peeling: A 3D Ngenuity Tool For Customized Treatment

We aimed to introduce a novel visualization technique of en-face scans during epiretinal membrane (ERM) peeling, by using the in-built picture-in-picture modality of the Alcon Ngenuity 3D System, connected to a smartphone.

Prospective monocentric interventional analysis on 20 patients undergoing vitrectomy and peeling for idiopathic ERMs. RTVue XR Avanti device was used perform a 6 × 6-mm optical coherence tomography angiography. En-face image from a custom slab from 9 µ m upon the internal limiting membrane to 30 µ m below the internal limiting membrane was taken and 180° flipped. The smartphone was connected to the Alcon 3D Ngenuity display using an HDMI-to-USB cable, and the picture-in-picture modality of the display was chosen in the software menu. Epiretinal membrane peeling was performed without dye stain starting from black linear structures on the en-face, indicating area of weaker adhesion to the ERM and could be used as cleavage point for membrane removal using vitreal forceps.

We reported successful peeling initiation and flap lift at the first forceps' grasp in all cases (100%). After ERM peeling, dual blue staining highlighted internal limiting membrane remnants in 15 cases (75%) and peeling was completed. Total surgical time, including cable connections and projection to the display, was 41.6 ± 9.2 minutes. Intraoperative total peeling time was 11.1 ± 2.6 minutes. Central macular thickness significantly reduced 1 month after surgery ( P = 0.01).

In summary, this is a cheap and easily reproducible surgical technique to optimize ERM management, offering an intraoperative guide for peeling initiation and minimizing unnecessary surgical maneuvers.