Even before COVID-19 swept the world, telemedicine incorporating live video streaming held the potential to significantly improve surgical education and bring higher-caliber training to medical students in underserved geographic regions. Such workflows have taken on dramatically greater importance during the pandemic, as surgeons reduce the number of non-essential personnel in the operating room (OR) for the safety of patients and staff.

Once accessible only to larger medical institutions, new cost-effective technology solutions are now enabling medical practices of all sizes to bring the in-room OR experience to clinical fellows, residents, students, and mentors anywhere in the world. For three forward-looking U.S. eye surgeons, Magewell’s USB Capture HDMI 4K Plus video capture devices have formed a crucial link in delivering live video of surgical procedures from their operating rooms to viewers otherwise unable to participate, including remote training of new surgeons in low-income countries.

Beyond the Operating Room

Based in Orlando, Florida, HEALTheia specializes in developing advanced, customizable telemedicine solutions and software for eye care. HEALTheia CEO and co-founder S.K. Steven Houston III, MD – who is also a vitreoretinal surgeon and partner at the Florida Retina Institute – began piloting telesurgery workflows incorporating live streaming technologies in late 2019. Dr. Houston and fellow HEALTheia partner Dr. John Miller – director of retinal imaging at Massachusetts Eye and Ear in Boston and an assistant ophthalmology professor at Harvard Medical School – were developing an online retinal surgery education website, with a plan to incorporate live streaming channels. Dr. Houston quickly found their work gaining new significance early in 2020.

“The current climate of COVID means that we can’t have as many observers such as medical students in the operating room, as we need to reduce the risk of exposure,” explained Dr. Houston. “Streaming outside the OR allows a much larger population of residents and medical students to watch the surgeries.”

The technical centerpiece of many ophthalmology operating rooms is the NGENUITY^® 3D Visualization System from Alcon Inc. Designed to provide retinal surgeons with greater depth and detail during surgery than traditional microscopes, NGENUITY enables them to operate in a heads-up manner while looking at a 55-inch, 4K, OLED screen rather than peering through the oculars of a microscope. Dr. Houston began researching solutions for live streaming the output of the NGENUITY platform.

“Dr. Miller tried various options for live streaming the NGENUITY output, but they were somewhat expensive, which is less viable particularly in countries that are less affluent than ours,” said Dr. Houston. “Our goal was to balance our technical requirements with the accessibility of an off-the-shelf solution at a reasonable cost.”

Of course, visual fidelity was crucial given the precision required for surgical applications, but ease of use was also an important criterion. “We want doctors to be able to implement this workflow themselves, so we needed to make it as simple as possible,” Dr. Houston explained. “Many doctors may not have any streaming experience, so we wanted a solution that they would still be able to use.”

Dr. Houston’s research led him to Magewell’s USB Capture 4K Plus HDMI. “The Magewell capture device has given us a widely-available, plug-and-play option that we can recommend to our colleagues and is affordable to all comers,” he said.

The live HDMI output from the NGENUITY system goes into the USB Capture Plus device, which in turn sends the video over a standard USB connection into a computer running OBS (Open Broadcaster Software^®) and Zoom^®. OBS is used to combine video of the surgeon’s hands from a separate camera with the NGENUITY output, with Zoom delivering the combined result to remote participants with lower latency than available with typical streaming protocols and services.

In addition to its plug-and-play simplicity and affordable price point, Dr. Houston also praises the Magewell device’s reliability as well as its form factor. “The Magewell unit is compact and doesn’t need any external power source or cooling, which is ideal for space-constrained OR environments where we don’t want additional cords and fans,” he elaborated.

Educating Surgeons in Less Fortunate Countries

In addition to its use by Dr. Houston and Dr. Miller, HEALTheia’s live surgery workflow has been put into valuable, practical use by Advanced Center for Eyecare Global. ACE Global is a non-profit organization focused on training and empowering the next generation of ophthalmologists in the developing world.

“Our major goal is working towards blindness prevention by educating eye surgeons,” said Dr. Kevin Barber, president of ACE Global and certified ophthalmologist. "The leading cause of blindness in the world is cataracts, but there are just not enough cataract surgeons that have enough training, particularly in low-income countries. Our contribution to blindness prevention is to train more surgeons, better surgeons, and more efficient surgeons.”

For years, ACE Global has been partnering with residency programs in countries such as Honduras, Haiti, and El Salvador, making three or four trips each year to teach surgical students in person. Dr. Barber’s team was packing their bags to leave for Honduras in March 2020 when the pandemic put the brakes on that journey.

Needing a way to continue ACE Global’s work, Dr. Barber came across a medical journal article by Dr. Houston and Dr. Miller that outlined their Magewell-enabled workflow. Dr. Barber contacted Dr. Houston, who came to Dr. Barber’s operating room in late April to perform a test run. The success of that test led Dr. Barber to purchase his own Magewell USB Capture 4K Plus HDMI unit, and he began broadcasting live surgeries through Zoom to residents the following week.

“Since then, we have logged around 150 hours of live surgical training with NGENUITY through the Magewell device,” said Dr. Barber. “Remote surgeons can see exactly what I see, and we can have a live dialog while I am operating.”

Dr. Barber concurs with Dr. Houston’s assessment of the ease of use and affordability of the Magewell device. “It’s so inexpensive and simple,” he explained. “I am not a technical guy, but I’m able to do this cool stuff without feeling hindered by learning a complex process. I can set it up in the operating room within five minutes and be streaming to a global audience.”

Dr. Barber also lauds the visual fidelity of the Magewell capture solution. “There’s no degradation of the NGENUITY output,” he said. “The image quality is impeccable.”

The Magewell-enabled workflow has proven valuable in enabling ACE Global to continue and expand its mission. “It has become a very powerful educational tool that we didn’t have before, and our use has been expanding,” said Dr. Barber. “We have now streamed to medical students in Honduras, Dominican Republic, Peru, El Salvador, and Mexico, and can connect ORs anywhere in the world.”

Earlier this year, in conjunction with blindness prevention non-profit Orbis International, ACE Global presented a global live surgical stream that was viewed by surgeons in 81 countries. ACE Global has also received a research grant from Alcon to install an NGENUITY system and Magewell unit in Honduras, allowing doctors there to stream live surgeries back to the U.S. for mentoring and evaluation.

An Eye to the Future

Dr. Miller and Dr. Houston have also been exploring interactive telementoring as the next step in streamed surgical education, with Dr. Miller pioneering workflows that also incorporate 5G wireless technology. Beyond that, Dr. Houston sees today’s streaming success as paving the path towards even more powerful medical opportunities.

“Ultimately this type of work – the ability to stream live surgeries, view them, and interact – opens up the possibility of remote robotic surgery where someone could operate and assist from anywhere in the world without even being in the same country as the patient,” he concluded. “We’re just in the beginning innings, but already the Magewell device is enabling us to make a difference.”