The storied evolution of operating microscopes for intraocular surgery includes more than a century of landmark developments.1 Early advancements include the integration of stereo visualization by Zeiss Corporation in the 1890s, the first use of a binocular microscope for ophthalmic surgery in the 1940s, and gradual refinement in the 2000s with myriad innovations in optics, depth, and ease of use. These developments culminated in the more recent introduction of 3-dimensional (3D) visualization.2
Figure 1A. Head-mounted display.
Figure 1B. Heads-up display.
3D systems have been developed to provide a digital stereoscopic view of the surgical field free from the constraints of microscope eyepieces using either a large high-definition display screen (Figure 1A) or head-mounted display (HMD) units (Figure 1B). 3D heads-up surgery offers benefits in ergonomics, efficiency, reduction in light exposure, and 3D visualization for all members of the surgical team. The systems carry risks of latency, surgical field limitations, color or image distortion, learning curve delay, peripheral viewing difficulty, and the cost and logistics of implementation. Interested surgeons should weigh these advantages and limitations before investing in a specific system.
Currently available systems include Artevo (Zeiss), Ngenuity (Alcon), SeeLuma (Bausch + Lomb), and Beyeonics One (Beyeonics Vision/BVI Medical). The safety and efficacy of these systems have been established, with multiple reports showing no clinical, anatomic, or visual acuity differences between 3D visualization systems and conventional microscopy in macular or retinal detachment surgeries.3-6 Ngenuity uses a 3D digital camera mounted on a standard scope, whereas Artevo is an integrated digital microscope. Both use flat panel display screens for heads-up viewing. Beyeonics One provides an augmented reality HMD which is fully digital and uses the exoscope, which is a hands-free scope with gesture controls. Beyeonics One features automatic focus, pan, and zoom. The HMD has case series evidence for safety and efficacy, with unique benefits from hands-free operation and associated nuances in learning curve.7,8 Although a head-to-head comparison of HMDs vs 3D monitors has not yet been performed, many of the benefits of 3D heads-up surgery are similar across devices, with most studies reporting on screen-based Ngenuity or Artevo systems.3
Figure 2. Heads-up display requiring perfect orientation of screens in operating room. Assistant surgeon must adopt a head turn to view operating screen.
Illumination
The lower illumination needed for digital systems may reduce theoretical risks of iatrogenic retinal light injury.9 Pars plana vitrectomy for retinal detachment repair with 3D systems can be completed under lower illumination intensity compared to traditional microscopes.10 Adjustments in optical parameter profiles may further facilitate visualization of epiretinal membrane or internal limiting membranes,11 potentially reducing the amount of intraoperative dye. 3D surgical systems purport higher depth of field compared to traditional microscopes, with some studies showing less intraoperative adjustments for membrane peeling in delicate macular surgeries.12
Ergonomics
Musculoskeletal disorders and back pain are well-known occupational risks to ophthalmologists.13,14 In terms of operating room ergonomics, standard microscopes are believed to promote head-forward and back-arched positioning that promotes muscle fatigue. This may be reduced in digital 3D systems.15 In addition to surveys showing improvement in back and neck pain, objective measures of neck and back muscle tone have shown improved ergonomics with digitally assisted systems.16 If these systems allow retinal surgeons to perform more surgeries, or continue their surgical careers without risk of chronic musculoskeletal issues, these systems may be well worth the investment.
Educational Value
3D surgical videos may have increased educational value compared to 2D recordings, especially for medical students and early learners.17 A survey of clinicians across the vitreoretinal surgical team found a generally positive impact of 3D displays during surgery, though there were worse reported user experiences when performing endolaser, closing, and scleral fixation of intraocular lenses.18 Further, pilot data suggest these systems could allow telesurgery,19 which could have significant implications for patient access, collaboration, and education.
Figure 3. Examples of viewing difficulty with current systems: endolaser difficulty with visualization of aiming beam (A), digitization artifact (B), difficulty with peripheral visualization (C), and oversaturated colors and misalignment with surgeon view (D).
Limitations
Early work with 3D heads-up display has also been shown to require longer macular peel times and less ease of use, which suggests a learning curve during adoption of the new technology.20 Similar reports show increased surgical duration with 3D systems for retinal detachment repair,21 which decreases with experience. Other studies have shown similar surgical timing with 3D systems.22 There may be surgeon-specific factors in utilization, and emerging trainees with more exposure to virtual or augmented reality outside of the operating room may find heads-up HMD more easily integrated into their practice. In any case, the potential for adjustment for all members of the surgical team should be considered.
There are additional notable shortcomings of 3D systems that should be considered by vitreoretinal surgeons. Headsets for surgeons and assistants could cause head discomfort or fogging from condensation and can introduce cumbersome additional steps in surgery if the headset or display is not used for the entire case (Figure 2). The machine must be properly positioned and could create obstacles in the operating room, including limiting anesthesia access to patients.18 Early reports of latency may be less clinically meaningful with improvements in engineering.23 Other considerations include possible distortion from digitized images or oversaturated colors, and challenges in peripheral viewing (Figure 3). Finally, 3D systems require variable capital expenditure, storage, maintenance, and integration of large new equipment into existing operating rooms. These investments may be administratively or logistically difficult, especially for cost-conscious ambulatory surgical settings, in lieu of robust improvements in clinical outcomes.
Figure 4. Integrated operating room with immersive digital visualization and iOCT (A) and head-mount display control (B).
Future Directions
Future innovations in 3D viewing systems may continue to augment the surgical experience. In the DISCOVER study, integration with 3D surgical visualization systems allowed simultaneous viewing of OCT and the surgical field (Figure 4).24 As a result, this system was shown to augment surgical visualization efficiency, with less illumination, and ergonomic benefits compared to conventional microscope intraoperative OCT.25,26 Similar findings are shown with HMDs, without the need for reverting to a conventional microscope.27 Future developments such as improved image processing software could fundamentally shift the risk-benefit calculus for adopting these systems. RP
References
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