Heads-up Cataract Surgery: Complication Rates, Surgical Duration, and Comparison With Traditional Microscopes

Relationship between Image Quality and Reproducibility of Surgical Images in 3D Digital Surgery

Objectives: Ophthalmic three-dimensional (3D) digital surgery can reproduce high-definition surgical images; however, 3D digital surgery is limited by recording capacities. We examined the relationship between the minimum image quality required to reproduce surgical images and recording capacity. Methods: Patients who underwent simultaneous vitrectomy and cataract surgery by the same surgeon using a 3D digital surgery system at Juntendo University Urayasu Hospital between February and October 2021 were evaluated. Various quality (Q) and frame rate (FR) settings were used for each case. Four vitreous surgeons evaluated the reproducibility of recorded images of macular manipulation for epiretinal membrane (ERM) and macular hole (MH) cases and those of peripheral retinal manipulation for rhegmatogenous retinal detachment (RRD) cases. The video bitrate and minimum settings required to reproduce surgical images and factors affecting surgical image reproducibility were examined. Results: A total of 129 eyes of 129 patients were observed. The minimum image quality required to reproduce surgical images was 11.67 Mbps. The Q and FR for periretinal processing and Q for macular manipulation affected surgical image reproducibility (p = 0.025, p = 0.019, and p = 0.07, respectively). The minimum recording settings required to obtain highly reproducible images were Q = 3 and FR = 40. The total file size for vitrectomy video recordings with these settings was as compact as 3.17 GB for 28 min. Conclusions: During 3D digital surgery, highly reproducible surgical images can be obtained with a small storage capacity using settings of at least Q = 3 and FR = 40.

3D Heads-up digital filters for cataract surgery and corneal transplantation

PURPOSE

To describe the advantages of Ngenuity 3D digital filters for enhancing visualization during cataract and corneal transplant surgery.

METHODS

All surgeries were performed by the same experienced surgeon (L.M.) using the Ngenuity 3D heads-up visualization system connected to a microscope. Images were simultaneously captured with and without the filter in each of the following phases: endothelial evaluation, capsulorhexis, capsule rupture, vitreous leak, cortex removal, visco removal, corneal suture, descemetorhexis, DMEK graft preparation and insertion.

RESULTS

In cataract surgery, green and monochrome filters facilitate capsulorhexis in difficult situations by highlighting the anterior capsule and can improve visualization of a posterior capsular tear. The enhanced contrast of the monochrome filter is also useful for cortex and viscoelastic removal. In corneal surgery, the green filter highlights the rim of the DMEK graft during tissue preparation, the yellow filter enhances the contrast of the stained DMEK graft in the anterior chamber, the monochrome filter simplifies descemetorhexis by improving visualization of the Descemet/endothelial layer and allows a better view in red saturated images while performing sutures.

CONCLUSIONS

Ngenuity digital filters have the potential to enhance tissue visualization during cataract and corneal surgeries, especially in poor visibility conditions.

Light as a drug: prospective randomized evaluation and comparison of the effect of decreased illumination on visual recovery after cataract surgery

PURPOSE

To compare the effect of decreased illumination on the rate of postoperative visual recovery, and the incidence of cystoid macular edema (CME) with surgical visualization achieved with a traditional analog operating microscope compared with a 3D digital visualization system.

SETTING

Ambulatory surgery center, New York.

DESIGN

Prospective, randomized, consecutive, single-surgeon series.

METHODS

Patients undergoing routine cataract surgery were randomized into either (1) visualization through the binoculars of a standard operating microscope ("traditional group") or (2) visualization through a 3D digital visualization system affixed to the same operating microscope ("digital group"). Note was made in each case of light intensity used, light exposure time, cumulative dissipated energy (CDE), femtosecond laser use, preoperative medical and ocular conditions, intraoperative and/or postoperative complications, and preoperative and postoperative visual acuities and optical coherence tomography confirmed CME.

RESULTS

The study comprised 118 eyes in the traditional group and 96 eyes in the digital group. There were no differences in preoperative visual acuity, light exposure time, CDE, or femtosecond laser use between groups, but the light intensity used in the digital group was significantly less (19.5% ± 0.5%) than in the traditional group (48.6% ± 0.6%; P < .001). Furthermore, the digital group achieved a better decimal postoperative day 1 visual acuity (0.60 ± 0.03) with less rates of CME (2.1%) when compared with that of the traditional group (0.51 ± 0.02, P = .03; and 9.2%, P = .03), respectively.

CONCLUSIONS

Visual recovery and CME rates were significantly better in patients who underwent cataract surgery assisted by the 3D digital visualization platform without an increase in complications or surgical time.

Comparison of posterior capsule rupture rates during phacoemulsification using 3D heads-up visualization system and traditional microscopes

PURPOSE

To compare the posterior capsule rupture (PCR) rates of cataract surgery using a traditional ophthalmic surgical microscope (OSM) and a 3D heads-up visualization system (HUVS).

SETTING

Single tertiary referral center.

DESIGN

Retrospective study.

METHODS

This study included 10 101 eyes that underwent phacoemulsification cataract surgery. Surgeries were performed using either 3D HUVS (1964 eyes, performed by 2 surgeons, HUVS group) or traditional OSM (8137 eyes, performed by 6 surgeons, OSM group) from February 2018 to June 2022. Data were collected based on the diagnosis-related group system, and the rate of PCR requiring vitrectomy and the surgical time were evaluated.

RESULTS

The PCR rates were not significantly different between the OSM (n = 63; 0.7%) and HUVS (n = 19; 0.9%, P = .392) groups. The mean surgical time was significantly longer in the HUVS group (14.7 ± 10.6 minutes) than in the OSM group (12.9 ± 9.9 minutes, P < .001). In the 3D HUVS group, there were no PCR cases among the initial 100 patients. In both groups, no significant difference was observed in the PCR rates over time. Although the difference was not statistically significant, the PCR rate decreased over time in the HUVS group.

CONCLUSIONS

The results indicate that 3D HUVS-based cataract surgery performed by experienced cataract surgeons had a PCR rate similar to that of traditional OSM-based surgery during the 4-year study period. Although the surgical time was slightly longer with 3D HUVS, cataract surgery using 3D HUVS can be performed safely by experienced surgeons.

Comparison of three-dimensional heads-up system versus traditional microscopic system in medical education for vitreoretinal surgeries: a prospective study

BACKGROUND

To compare the value and efficiency of the three-dimensional (3D) heads-up surgical system and traditional microscopic (TM) system in teaching and learning vitreoretinal surgeries.

METHODS

Twenty ophthalmologists and scrub nurses were recruited as teachers, and 45 junior ophthalmology residents and trainee doctors, trainee nurses, and medical students were recruited as observers. Each teacher and observer were assigned to both a 3D-assisted and TM-assisted vitreoretinal surgery and then asked to complete satisfaction questionnaires for both surgical systems at the end of each surgery.

RESULTS

The 3D heads-up surgical system was rated significantly higher in most of the subscales and overall satisfaction score by both teachers and observers (P < 0.05). However, ratings for instrument adjustment were significantly higher in the TM group compared to the 3D group for junior ophthalmology residents and trainee doctors (6.1 ± 1.7 vs. 8.8 ± 1.1, P < 0.001).

CONCLUSIONS

The 3D heads-up surgical system has great didactical value in the medical education of vitreoretinal surgeries, but it is important to consider the specific needs of different learners when choosing between the two systems.

TRIAL REGISTRATION

Not applicable.

Comparison of cognitive workload and surgical outcomes between a three-dimensional and conventional microscope macular hole surgery

BACKGROUND

Performing a surgical task subjects the surgeon to multitudinal stressors, especially with the newer 3D technology. The quantum of cognitive workload using this modern surgical system in comparison to the Conventional microscope system remains unexplored. We evaluate the surgeon's cognitive workload and the surgical outcomes of macular hole(MH) surgery performed on a 3D versus a Conventional microscope operating system.

METHODS

50 eyes of 50 patients with MH undergoing surgery using the 3D or Conventional microscope visualization system. Cognitive workload assessment was done by real-time tools(Surgeons' heart rate [HR] and oxygen saturation[SPO2]) and self-report tool(Surgery Task Load Index[SURG-TLX] questionnaire) of three Vitreoretinal surgeons. Based on the SURG-TLX questionnaire, an assessment of the workload was performed.

RESULTS

Of the 50 eyes, 30 eyes and 20 eyes underwent surgery with the Conventional microscope and the 3D system, respectively. No difference was noted in the MH basal-diameter(p = 0.128), total surgical-duration(p = 0.299), internal-limiting membrane(ILM) peel time(p = 0.682), and the final visual acuity (VA; p = 0.515) between the two groups. Both groups showed significant improvement in VA(p < 0.001) with a 90% closure rate at one-month post-surgery. Cognitive workload comparison, the intraoperative HR(p = 0.024), total workload score(P = 0.005), and temporal-demand dimension(p = 0.004) were significantly more in Conventional microscope group as compared to 3D group. In both the groups, the HR increased significantly from the baseline while performing ILM peeling and at the end.

CONCLUSION

The surgeon's cognitive workload is markedly reduced while performing macular hole surgery with a 3D viewing system. Moreover, duration of surgery including ILM peel time, MH closure rates, and visual outcomes remains unaffected irrespective of the operating microscope system.

Cataract surgery using two 3D visualization systems: Complication rates, surgical duration & comparison with traditional microscopes

PURPOSE

To compare the complication rates and surgical duration of cataract surgery using two 3D visualization systems and a traditional binocular microscope among experienced and inexperienced surgeons.

METHODS

This retrospective case series included 571 eyes that received cataract surgery using either heads up cataract surgery, via a 3D head mounted system (N = 148-Group 1) or a 3D display screen (N = 338 eyes-Group 2), or traditional binocular microscope (N = 85 eyes-Group 3). The surgical records of consecutive patients who underwent cataract surgery by two groups of surgeons (experienced and inexperienced) were reviewed. Patients in all groups received either femtosecond laser assisted cataract surgery (FLACS) or traditional phacoemulsification. Complication rate, as well as duration of cataract surgery were evaluated between all three visualization approaches, between experienced and inexperienced surgeons.

RESULTS

There was no statistically significant difference in duration of surgery between all 3 visualization approaches for both experienced and inexperienced surgeons (p < 0.05). Furthermore, the type of surgical technique (manual or FLACS) did not affect the surgical duration for both experienced and inexperienced surgeons (p < 0.05). No intraoperative complications were demonstrated in the current cohort.

CONCLUSIONS

The implementation of heads up-3D visualization either through a screen or a head mounted platform for cataract surgery seems to offer similar safety and efficiency as the traditional binocular microscope, and both experienced and inexperienced surgeons demonstrate the same outcomes in terms of safety and efficiency.

3D visualization system and standard operating microscope for ease of visualization and surgeon comfort during phacoemulsification surgery

PURPOSE

To compare the ease of visualization and comfort of the surgeon during phacoemulsification surgery using NGENUITY® 3D (NG) visualization system and standard operating microscope (SOM).

METHODS

In this prospective, randomized, single-blind, single-center study, patients undergoing phacoemulsification surgery by one of the five surgeons were randomly assigned to two groups based on the visualization modality-NG and SOM. Ease of visualization and comfort of the surgeon was assessed using a 27-parameter in-house Surgeon Comfort Score questionnaire.

RESULTS

A total of 224 phacoemulsification with intraocular lens implantations were performed in senile immature cataract (SIMC, n = 174) and mature cataract patients (MC, n = 50). Surgeon's ease of visualization (4.92-5.00) and hand-eye coordination score (4.97-5.00) were comparable between the NG- and SOM-groups. Postoperative neck discomfort was lower in both the groups, with a relatively lower discomfort in the NG-group (score: 1.04 vs 1.56). The Spearman rank correlation coefficient (r) between illumination of the operation theatre room and the surgical field revealed a weak negative correlation for most of the patients in the NG-group, and a positive correlation for patients in the SOM-group. No correlation was obtained between brightness of the surgical field and comfort with the surgical field brightness.

CONCLUSIONS

Similar ease of visualization was experienced by the surgeons using NG- and SOM-system. Neck discomfort postsurgery was numerically lower in the NG-group, although not significant. Additionally, the NG-system permitted the safe performance of phacoemulsification using a lower surgical field illumination.

Enhancing surgical precision and efficiency: a study and comparison of a three-dimensional surgical video system in proliferative diabetic retinopathy surgery

Purpose

This study aimed to investigate the safety and efficacy of three-dimensional (3D) surgical video systems for proliferative diabetic retinopathy (PDR).

Methods

This retrospective clinical case study included 30 patients (30 eyes) with PDR. Patients were divided into two groups: one underwent surgery using a 3D surgical video system (14 cases, 14 eyes), while the other underwent traditional microscope surgery (16 cases, 16 eyes). Safety and efficacy were assessed through predetermined surgical parameters, including surgical duration, intraoperative membrane removal rate, and occurrences during intraoperative and postoperative phases.

Results

Our study revealed noteworthy differences in various aspects between the 3D surgical video system group and the traditional microscope surgery group. Specifically, the mean surgical time was 30.25 ± 14.43 mins in the 3D surgical video system group, while it was 38.56 ± 18.71 mins in the traditional microscope surgery group (p = 0.051). Furthermore, the mean membrane removal time was significantly shorter in the 3D group at 2.53 ± 1.52 mins, as compared to 3.23 ± 1.76 mins in the traditional group (p = 0.042). Importantly, the membrane removal rate also displayed a significant difference, with the 3D group at 0.55 ± 0.07 and the traditional group at 0.41 ± 0.11 (p = 0.018). However, no notable differences were observed between the two groups in terms of intraoperative and postoperative incidences.

Conclusion

The safety and efficacy obtained using the 3D surgical video system in PDR surgery were comparable to those obtained in traditional microscopic surgery.

Quality assessment and comparison of two- and three-dimensional YouTube videos as additional educational tools for cataract surgery: "METAVERSE"

BACKGROUND

To compare the content and quality of 3D YouTube videos with 2Ds as additional educational tools for phacoemulsification surgery.

METHODS

This cross-sectional study included 2D and side-by-side 3D phacoemulsification videos found on YouTube by searching for "phacoemulsification," "phaco," and "cataract." Data was collected on video length (min), time since upload (days), number of views, likes, dislikes, cataract type, chop technique, and visualization system. Video popularity and interaction were calculated by video power index, interaction index, and viewing rate. Two senior ophthalmologists (SOs) and two ophthalmology residents (ORs) evaluated videos using the DISCERN, global quality score (GQS), and usefulness scoring systems. Inter-rater reliability was assessed using intra-class correlation coefficient (ICC).

RESULTS

A total of 457 videos were screened, with 85 in 2D and 85 in 3D deemed appropriate for analysis. 2D videos received significantly more views, likes, dislikes, days since upload, video power index, and viewing rate than 3Ds (p < 0.001). Video length and interaction index in 3D videos were significantly greater than in 2Ds (p < 0.001). All video scoring systems revealed that 3D videos outperformed 2Ds in ORs (p < 0.05). ICC confirmed good inter-rater reliability agreement even at the lowest value (SOs: 0.924, 95% CI, 0.910-0.937; ORs: 0.892, 95% CI, 0.878-0.908).

CONCLUSIONS

3D YouTube videos as additional educational tools could help not only SOs but also ORs fully comprehend the breadth and depth of ocular surgeries, particularly phacoemulsification, by improving depth perception. They can also be used to review previously learned procedures, observe new ones, and recall old ones.

The Implementation of Glasses-free 3D Display in ICL Surgery: A Pilot Study

PURPOSE

To compare the efficacy and safety of the glasses-free three-dimensional (3D) display and conventional optical microscope in Implantable Collamer Lens (ICL; STAAR Surgical) surgery.

METHODS

This randomized controlled trial enrolled 51 eyes of 26 patients who received ICL surgery. After random allocation, patients received surgery under either a glasses-free 3D display (16 eyes) or a conventional optical microscope (35 eyes). The surgical duration, uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), intraocular pressure, vault, postoperative manifest refraction spherical equivalent (MRSE), and complications were evaluated.

RESULTS

Mean surgical time was 5.04 ± 2.74 minutes for the glasses-free 3D group and 4.65 ± 2.63 minutes for the conventional microscope group (P = .639). Postoperative UDVA was -0.02 ± 0.04 and -0.04 ± 0.05 logMAR (P = .169), CDVA was -0.03 ± 0.04 and -0.02 ± 0.05 logMAR (P = .434), and IOP was 17.01 ± 3.15 and 14.82 ± 2.20 mm Hg (P = .055) at 1 month of follow-up, respectively. Vault was 562.86 ± 192.89 and 520.18 ± 215.19 µm, and MRSE was +0.25 ± 0.21 and +0.10 ± 0.51 diopters, respectively, at 1 month postoperatively; all were comparable between the glasses-free 3D group and conventional microscope group (all P > .05). No complication occurred in both groups.

CONCLUSIONS

The glasses-free 3D group achieved similar efficacy and safety compared to the conventional microscope group, and glasses-free 3D surgery is expected to show a significant advantage in clinical and medical education. [J Refract Surg. 2023;39(9):612-619.].

Evaluation of new approach to enhance visualization performance in cataract surgery: 3D visualization system with coaxial illumination

PURPOSE

To evaluate the visualization performance of different approaches, including the 3D visualization system with coaxial illumination and the 3D system or microscope with standard illumination.

SETTING

Fuzhou Eye Hospital, Fuzhou City, China.

DESIGN

Cross-sectional study.

METHODS

This 2-part performance assessment for visualization composed of an objective analysis using surgical video images and a subjective survey collecting feedback from surgeons. Data of each eye were obtained with 3 approaches: standard operating microscope with standard illumination (SOM-S), 3D visualization system with standard illumination (3D-S), and 3D visualization system with coaxial illumination (3D-C).

RESULTS

112 eyes (107 cases) and 6 cataract surgeons were involved. The red reflex value was markedly greater in the 3D-C approach compared with other 2 approaches ( P < .001). Compared with the SOM-S approach, the red reflex increased by 55%, 57%, and 53% in the 3D-C approach, corresponding to nuclear grades of II, III, and IV, respectively. In the questionnaire survey, red reflex scores were consistently significantly higher in the 3D-C approach than those in the others ( P < .001). Depth of field was enhanced in both 3D approaches compared with the SOM-S approach ( P < .05). The only minor advantage of the SOM system over the 3D-C approach was in the surrounding field clarity score, and the difference was not statistically significant ( P = 1.000).

CONCLUSIONS

The 3D-C approach significantly increased the red reflex in both objective and subjective assessments. Surgeon responses also showed a superior performance for the 3D-C approach.

Magnification and Refocusing Comparison in Cataract Surgery Using a Heads-Up Three-Dimensional Visualization System versus Conventional Binocular Microscopy

Purpose

To compare magnification and refocusing during phacoemulsification with the NGENUITY® 3-D Visualization System (3-D) versus the conventional microscope (CM) OPMI LUMERA 700.

Setting

This study was performed in the Department of Anterior Segment of the Fundación Hospital Nuestra Señora de la Luz.

Design

Prospective, randomized, cross-sectional, multi-surgeon, and comparative study.

Methods

This study enrolled 100 patients (eyes) scheduled for phacoemulsification to measure the number of times changes in focusing and magnification were needed during cataract surgery.

Results

Our study included 100 patients. From the endpoints evaluated, "zoom-in" showed statistically significant differences for all of the four predefined cataract surgery steps (means: Step 1, 0.38 (CM) vs 0.08 (3-D); Step 2, 0.36 (CM) vs 0.06 (3-D); Step 3, 0.54 (CM) vs 0.22 (3-D); Step 4, 0.56 (CM) vs 0.24 (3-D); all comparisons, p <0.05). In Step 4, there was a statistically significant increased use of "focus-out" for the 3-D system (mean 0.16 (CM) vs 0.58 (3-D); p <0.05). "Focus-in" and "zoom-out" showed no group differences for all steps. The duration of surgery with the 3-D system was longer at each step and overall. The percentage of light intensity did not show a statistically significant difference between both systems, with a mean of 99.45 for CM vs 98.43% for the heads-up system.

Conclusion

The heads-up 3-D system is a safe option that offers excellent magnification for anterior segment visualization. The surgical time is longer, but adjusting settings like light intensity and brightness may facilitate some surgical steps early in the learning curve.

Comparing microscope light-associated glare and comfort between heads-up 3D digital and conventional microscopes in cataract surgery: a randomised, multicentre, single-blind, controlled trial

OBJECTIVE

To compare subjective levels of comfort and visual experiences related to microscope light in patients undergoing their first cataract surgery with topical anaesthesia using a digital microscope (the NGENUITY three-dimensional (3D) visualisation system) or a conventional microscope.

METHODS AND ANALYSIS

A prospective, randomised, single-blinded, parallel-group, multicentre, interventional study. Patients (n=128) were randomly assigned to one of two treatment groups: the experimental group (n=63) had surgery using the digital microscope and the control group (n=65) had surgery with a conventional microscope. The primary outcome was patients' subjective experience of glare from the microscope light during surgery on a numerical scale from 0 to 10. Key secondary outcomes were patients' subjective levels of comfort and visual experiences related to the microscope light.

RESULTS

The experimental group reported significantly lower levels of glare; median levels were 1.0 (0.0-4.0) for the experimental group vs 3.0 (0.0-6.0) for the control group (p=0.027). They also reported higher levels of comfort; median ratings were 8.0 (6.5-10.0) in the experimental group and 7.0 (5.0-9.0) in controls (p=0.026). There were no group differences in ratings of subjective pain or visual disturbances. Median microscope light intensity was lower in the experimental group than controls; 3425.0 (2296.0-4300.0) Lux vs 24 279.0 (16 000.0-26 500.0) Lux (p<0.0001), respectively.

CONCLUSION

Compared with conventional microscopes, the NGENUITY 3D visualisation system allows surgeons to operate with lower levels of light exposure, resulting in significantly less glare and improved comfort in patients undergoing cataract surgery.

TRIAL REGISTRATION NUMBER

NCT05085314.

Three-Dimensional Visualization System for Vitreoretinal Surgery: Results from a Monocentric Experience and Comparison with Conventional Surgery

PURPOSE

To describe the experience of our centre (Careggi University Hospital, Florence, Italy) in using a heads-up three-dimensional (3D) surgical viewing system in vitreoretinal surgery, making a comparison with the conventional microscope surgery.

METHODS

We retrospectively analyzed data taken from 240 patients (240 eyes) with surgical macular diseases (macular hole and epiretinal membrane), retinal detachment or vitreous hemorrhage who underwent vitreoretinal surgeries, by means of the NGENUITY 3D Visualization System (Alcon Laboratories Inc., Fort Worth, TX, USA), in comparison with 210 patients (210 eyes) who underwent vitreoretinal surgeries performed using a conventional microscope. All surgeries were performed with standardized procedures by the same surgeons. We analyzed data over a follow-up period of 6 months, comparing the surgical outcomes (best-corrected visual acuity, anatomical success rate and postoperative complication rate) between the two groups.

RESULTS

the 3D group included 74 patients with retinal detachment, 78 with epiretinal membrane, 64 with macular hole and 24 with vitreous hemorrhage. There were no significant differences in the demographic and clinical characteristics between the 3D group and the conventional group. We found no significant differences in outcome measures at three and six months follow-up between the two groups (p-value ≥ 0.05 for all comparisons). Surgery durations were similar between the two groups.

CONCLUSIONS

In our experience, a heads-up 3D surgical viewing system provided comparable functional and anatomical outcomes in comparison with conventional microscope surgery, proving to be a valuable tool for vitreoretinal surgery in the treatment of different retinal diseases.

Use of Digital Methods to Optimize Visualization during Surgical Gonioscopy

Purpose: The aim of this study was to evaluate the efficacy of digital visualization for enhancing the visualization of iridocorneal structures during surgical gonioscopy. Methods: This was a prospective, single-center study on a series of 26 cases of trabecular stent implantation performed by the same surgeon. Images were recorded during surgical gonioscopy, and before stent implantation, with standard colors and with the optimization of various settings, principally color saturation and temperature and the use of the cyan color filter. Subjective analyses were performed by two glaucoma surgeons, and objective contrast measurements were made on iridocorneal structure images. Results: The surgeons evaluating the images considered the optimized digital settings to produce enhanced tissue visibility for both trabecular meshwork pigmentation and Schlemm's canal in more than 65% of cases. The mean difference in the standard deviation of the pixel intensity values was 37.87 (±4.61) for the optimized filter images and 32.37 (±3.51) for the standard-color images (p < 0.001). The use of a cyan filter provided a good level of contrast for the visualization of trabecular meshwork pigmentation. Increasing the color temperature highlighted the red appearance of Schlemm's canal. Conclusions: We report here the utility of optimized digital settings including the cyan filter and a warmer color for enhancing the visualization of iridocorneal structures during surgical gonioscopy. These settings could be used in surgical practice to enhance the visualization of the trabecular meshwork and Schlemm's canal during minimally invasive glaucoma surgery.

Comparison of novel digital microscope using integrated intraoperative OCT with Ngenuity 3D visualization system in phacoemulsification

OBJECTIVE

To compare surgical efficiency, visual and physical comfort, and safety profile of the ARTEVO 800 Digital Microscope (Carl Zeiss Meditec AG, Jena, Germany) and the Ngenuity 3D Visualization System (Alcon Laboratories Inc, Fort Worth, TX) in cataract surgery.

DESIGN

Cross-sectional study.

PARTICIPANTS

One hundred consecutive phacoemulsification cataract surgeries performed by five surgeons from June 1, 2020, to November 1, 2020.

METHODS

For each case, the surgeons answered a 2-section questionnaire (before and after intervention) to collect data on cataract severity or grade, surgical risk, chosen three-dimensional (3D) visualization system, surgical complications, and the visual or physical discomfort experienced during the procedure.

RESULTS

Each of the 5 surgeons performed 20 surgeries (N = 100) using either the ARTEVO 800 Digital Microscope (N = 50) or the Ngenuity Visualization System (N = 50). Mean duration of the surgical procedure was 17.07 ± 4.80 minutes, and none of the surgeons ever switched to the classical microscope. In addition, 40% of surgeries were considered at low risk, 30% at intermediate risk, and 30% at high risk. The Zoom, Focus, and XY commands were used 1-3 times, respectively, during 76 (p = 0.34), 73 (p = 0.49), and 76 (p = 0.64) interventions. Surgical uncertainty and operative fluency were similar using both systems (p = 0.53 and p = 0.19). We observed 14 intraoperative complications, 9 using Ngenuity and 5 using the ARTEVO 800. Surgeon's visual comfort (p = 0.79), colour or brightness perception (p = 0.82), and visual impairment (p = 0.62) during surgery were similar for both systems. Headache, backache, and other musculoskeletal problems were reported, respectively, after 14 (p = 0.79), 11 (p = 0.99), and 8 (p = 0.44) procedures.

CONCLUSION

Both the Ngenuity 3D Visualization System (Alcon Laboratories Inc) and the ARTEVO 800 Digital Microscope (Carl Zeiss Meditec AG) provided comparable operative speed and overall surgical comfort during cataract surgery.

Traditional analogue vs. three-dimensional digital visualization used in ophthalmic surgery

The visualization of the surgical process remains a topical issue in cataract surgery. The review presents the history of visualization technique in ophthalmic surgery and compares the main current analogue and 3D digital technologies. The advent of 3D imaging systems in clinical practice has helped solve many issues associated with the use of standard analogue microscopes. These issues include limited focus and field of vision, the need to use a large amount of light, which increases the risk of iatrogenic retinal phototoxicity, the surgeon's attachment to the microscope and, consequently, a high load on the surgeon's visual apparatus when using eyepieces, as well as on their back and neck muscles.

Operative Digital Enhancement of Macular Pigment during Macular Surgery

Purpose: To describe the feasibility of intraoperative digital visualization and its contribution to the enhancement of macular pigmentation visualization in a prospective series of macular surgery interventions. Materials and Methods: A prospective, single-center, single-surgeon study was performed on a series of 21 consecutive cases of vitrectomy for various types of macular surgery using a 3D visualization system. Two optimized filters were applied to enhance the visualization of the macular pigment (MP). For filter 1, cyan, yellow, and magenta color saturations were increased. Filter 2 differed from filter 1 only in having a lower level of magenta saturation for the green-magenta color channel. Results: Optimized digital filters enhanced the visualization of the MP and the pigmented epiretinal tissue associated with the lamellar and macular holes. In vitreomacular traction surgery, the filters facilitated the assessment of MP integrity at the end of surgery. Filter 1 enhanced MP visualization most strongly, with the MP appearing green and slightly fluorescent. Filter 2 enhanced MP visualization less effectively but gave a clearer image of the retinal surface, facilitating safe macular peeling. Conclusion: Optimized digital filters could be used to enhance MP and pigmented epiretinal tissue visualization during macular surgery. These filters open new horizons for future research and should be evaluated in larger series and correlated with intraoperative OCT.

Glycemic control and macular edema in patients undergoing cataract surgery

AIMS

Cataract, the most common cause of blindness, has higher prevalence among patients with diabetes mellitus. About 20% of cataract surgeries are performed on patients with diabetes. One of the complications of cataract surgery is pseudophakic cystoid macular edema (CME). This study examined whether patients' glycemic control (as indicated by HbA1c level before cataract surgery) is associated with CME incidence within one year post-surgery.

METHODS

We conducted a retrospective cohort study of 1285 diabetes patients over age 18 who underwent cataract surgery between January 2015 and January 2020. Data were obtained from medical records reporting glycated hemoglobin (HbA1c) level prior to surgery and post-operative CME with intraocular anti-vascular endothelial growth factor injections.

RESULTS

The patients with CME complications were younger, with longer duration diabetes, and higher percentages of type 1 diabetes and diabetic retinopathy. The main variables influencing risk of post-operative CME were found to be diabetic retinopathy and HbA1c level. Multivariate analysis revealed that HbA1c is an independent risk for post-operative CME with a relative risk of 2.01 when HBa1c is above 7 c (95% CI, 1.10-3.67).

CONCLUSION

The study demonstrates that pre-cataract surgery diabetes control, measured by HbA1c level, is an independent risk factor for developing post-surgery CME.

Impact of Heads-Up Display Use on Ophthalmologist Productivity, Wellness, and Musculoskeletal Symptoms: A Survey Study

Purpose

To explore how ophthalmologist productivity, wellness, and musculoskeletal (MSK) symptoms are affected by heads-up display (HUD) use.

Methods

A digital survey was emailed to the United States ophthalmologists. Questions covered topics including MSK health, surgical output, work hours, wellness hours, and factors related to HUD use.

Results

One hundred and forty-four ophthalmologists responded, and 99 completed all eligible questions. HUDs were utilized by 33 respondents, 29 of whom submitted complete surveys. HUD users worked 353 more hours annually (P = 0.01) and performed 673 more cases (P = 0.07) than nonusers. MSK symptom presence (P = 0.79), severity (P = 0.80), and frequency (P = 0.86) were independent of use. Over half (n = 16/29) of users identified symptomatic improvement attributable to the device, mostly in the cervical and lumbar regions. Mean job stress was moderate-severe for both users and nonusers (P = 0.10), and there was no significant difference in wellness hours (P = 0.44). Retina specialists (P = 0.02) and males (P = 0.03) were more likely to have operated with the technology. Nearly half of heads-up surgeons (n = 12/29) had obtained new equipment to target MSK symptoms, versus 1.4% of nonusers (n = 1/70; P = 0.0009). Most of those who operated with HUDs would recommend them to others (69.0%, n = 20/29), but 44.8% (n = 13/29) indicated ergonomic challenges. Primary concerns included awkward viewing angles, setup difficulties, and a lack of access.

Conclusions

HUD surgeons reported greater work output versus nonusers without significant compromises in wellness or MSK health. User feedback suggests that the technology may lessen neck and low back pains, but barriers including cost and system inconveniences may impede adoption.

Three-Dimensional Heads-up Display in Cataract Surgery: A Review

Intraocular visualization in cataract surgery is currently achieved using the ophthalmic surgical microscope (OSM). Three-dimensional (3D) heads-up display is a burgeoning intraocular visualization technique for cataract surgery, which projects the surgical view to a 3D monitor. A number of theoretical advantages of this system over the OSM have been proposed. 3D visualization is reported to provide improved depth perception and the heads-up display promotes a more ergonomic surgical position while providing an enhanced view for the entire surgical team. The modern OSMs, however, already allow for safe and efficient cataract surgery, and 3D heads-up display visualization is limited by a steep learning curve. We critically review the literature around 3D heads-up display cataract surgery and compare its safety profile to traditional visualization techniques.

Three-Dimensional Heads-Up vs. Standard Operating Microscope for Cataract Surgery: A Systematic Review and Meta-Analysis

Background: The surgical time duration, the postoperative best-corrected visual acuity (BCVA), and the incidence rate of intraoperative complications, alongside the vision and posturing parameters, were estimated by systematic review and meta-analysis to compare the three-dimensional (3D) heads-up visualization system (HUVS) and standard operating microscope (SOM) in cataract surgery. Methods: A literature search was conducted using PubMed, Embase, and Scopus on 26 June 2022. The weighted mean difference (WMD) was used to present postoperative BCVA and the mean surgical time duration, whereas the risk ratio (RR) was used to present the incidence rate of intraoperative complications. Publication bias was evaluated with Egger’s test. The Cochrane Collaboration’s Tool for randomized clinical trials, the methodological index for non-randomized, and the Newcastle-Ottawa Scale were used to assess the risk of bias. The research has been registered with the PROSPERO database (identifier, CRD42022339186). Results: In the meta-analysis of five studies with 1021 participants, the pooled weighted mean difference (WMD) of the postoperative BCVA showed no significant difference between patients who underwent HUVS versus SOM cataract surgery (WMD = −0.01, 95% confidence interval (CI): −0.01 −0.02). In the meta-analysis of nine studies with 5505 participants, the pooled WMD of mean surgical time duration revealed no significant difference between patients who underwent HUVS versus SOM cataract surgery (WMD = 0.17, 95% CI: −0.43–0.76). In the meta-analysis of nine studies with 8609 participants, the pooled risk RR associated with intraoperative complications was 1.00 (95% CI, 1.00–1.01). Conclusions: 3D HUVS and SOM provide comparable surgical time duration, postoperative BCVA, and incidence rate of intraoperative complications.

3D Visualization System in Descemet Membrane Endothelial Keratoplasty (DMEK): A Six-Month Comparison with Conventional Microscope

Background: To compare the efficacy and safety of Descemet membrane endothelial keratoplasty (DMEK) surgery using the three-dimensional (3D) display system NGENUITY to DMEK surgery performed with the traditional microscope (TM) in patients affected by Fuchs Endothelial Corneal Disease (FECD). Methods: Retrospective comparative study of 40 pseudophakic eyes of 40 patients affected by FECD who underwent DMEK surgery. Twenty patients (3D group) were operated on using the 3D display system and 20 patients (TM group) were operated on using the traditional microscope. Best spectacle corrected visual acuity (BSCVA), central corneal thickness (CCT), endothelial cell density (ECD) and corneal densitometry (CD) values were documented before and at 1, 3 and 6 months after DMEK. Intra- and postoperative complications were recorded. Results: The baseline assessments did not differ between the two groups (p > 0.05). Global surgical time and time to perform descemetorhexis were significantly lower in the TM group (p = 0.04 and p = 0.02, respectively). BSCVA, CCT, ECD and CD values did not differ significantly in the two groups at all follow-ups (p > 0.05). Complication rate was similar between the two groups. Conclusion: Three-dimensional display systems can be securely employed in DMEK surgery considering the satisfactory clinical outcomes, including Scheimpflug CD. Nevertheless, the slightly longer surgical time of the 3D DMEKs may lead to surgeons’ hesitancy. The main advantages of the heads-up approach may be the improved ergonomic comfort during surgery and the utility of assistants in surgical training.

Use of Black-and-White Digital Filters to Optimize Visualization in Cataract Surgery

Purpose: To evaluate the effect of a black-and-white (BW) filter on the optimization of visualization at each stage of cataract surgery. Methods: Prospective, single-center, single-surgeon, consecutive case series of 40 patients undergoing cataract surgery with BW filter. Surgical images and videos were recorded with and without the BW filter at each stage of cataract surgery. Contrast measurements of surgical images and subjective analysis of video sequences were performed. Results: The surgeons assessed the BW filter to optimize the tissue visibility of capsulorhexis contours, hydrodissection fluid wave perception, the contrast of instruments through a nucleus during phaco-chop, and subincisional cortex contrast through the corneal edema. Despite the higher contrasts’ value obtained with BW filter images during nucleus removal, posterior capsular polishing and viscous removal, the surgeons subjectively reported no significant advantage of using a BW filter. Standard color images were found to be better for localizing the limbal area during incision and for nucleus sculpture to assess groove depth. Conclusions: In conclusion, we describe here the potential indications for BW filter use at particular stages in cataract surgery. A BW filter could be used, with caution, in cases of poor visualization.

Comparison of Three-Dimensional Surgical System Versus Binocular Microscope for Clear Corneal Incision in Cataract Surgery

INTRODUCTION

To compare surgical outcomes of 2.2 mm clear corneal incision (CCI) between a three-dimensional (3D) visualization system and traditional binocular microscope (BM) for phacoemulsification and intraocular lens implantation surgery.

METHODS

In this randomized controlled clinical study, 60 eyes with age-related cataracts were divided into two groups receiving cataract surgery using either a 3D vision system (n = 30 eyes) (3D group) or a binocular microscope (n = 30 eyes) (BM group). We recorded and statistically analyzed surgical parameters and pre- and postoperative ocular parameters. Primary outcomes included the change in endothelial cell density (ECD) and CCI architecture, and secondary outcomes comprised other ocular parameters and surgical parameters. All procedures complied with the tenets of the Declaration of Helsinki.

RESULTS

Of the 60 eyes randomly assigned between January 5, 2021, and May 9, 2021, 55 (26 eyes in the 3D group and 29 eyes in the BM group) were analyzed. The ECD loss rate was 8.1% in the 3D group and 12.3% in the BM group, but the difference was not statistically significant. Local detachment of Descemet's membrane was seen in 50% (13 eyes, 3D group) and 51.6% (15 eyes, BM group), wound gaping at the endothelial side in 15.4% (four eyes, 3D group) and 10.3% (four eyes, BM group), gaping at the epithelial side in 11.5% (three eyes, 3D group) and 6.9% (two eyes, BM group), and misalignment of the incision in 3.4% (one eye, BM group) 1 day after surgery. These abnormalities improved with time. There was no difference between the 3D group and BM group in terms of other ocular parameters or surgical parameters before and after surgery.

CONCLUSIONS

Using the 3D surgical system for phacoemulsification and IOL implantation surgery seems to result in similar ECD and CCI conditions as using a conventional binocular microscope.

TRIAL REGISTRATION

The protocol was registered on ClinicalTrials.gov (NCT04839250).

Facilitating Role of the 3D Viewing System in Tilted Microscope Positions for Cataract Surgery in Patients Unable to Lie Flat

Purpose: To assess the utility of the 3D viewing system in tilted microscope positions for the performance of cataract surgery in challenging positions, for patients with difficulty remaining supine. Methods: Prospective, single-center, single-surgeon, consecutive case series of patients undergoing surgery in an inclined position. Results: 21 eyes of 15 patients who had undergone surgery at inclined positions at angles of 20° to 80°, with a mean angle of 47.62°. Surgeon comfort was considered to be globally good. The surgeon rated red reflex perception and the impression of depth as good and stable in all cases. The operating time was slightly longer for patients inclined at angles of more than 50°. On the first day after surgery, BSCVA was 20/25 or better in all cases. No ocular complications occurred in any of the interventions. Conclusions: Due to the ocular-free design of the 3D system, the surgical procedure and the positioning of the surgeon remained almost identical to that for patients undergoing surgery in a supine position, maintaining the safety of the standard surgical approach.

Vitrectomy Combined with Cataract Surgery for Retinal Detachment Using a Three-Dimensional Viewing System

Purpose: To evaluate the results of a pars plana vitrectomy (PPV) combined with cataract surgery for primary rhematogenous retinal detachment (RD) using a three-dimensional (3D) viewing system and a conventional microscope (CM). Methods: Medical reports of 82 patients were retrospectively reviewed: 26 patients were operated on with 3D and 56 patients were operated on with CM. The main outcome measures were visual acuity, duration of the surgery, and the rate of postoperative complications. Results: No statistically significant differences in pre- and postoperative visual acuity were found between both groups. There was significant improvement in the visual acuity in both groups. The best postoperative visual acuity was achieved with SF6 gas tamponade, followed by C3F8 gas and silicone oil in both groups. The duration of the surgery (60 min vs. 55 min) and the rate of postoperative complications (15% vs. 14%) were similar in both groups. Conclusions: The similar postoperative visual acuity and rate of complications detected using 3D and CM indicate that the 3D viewing system may be advantageous in the treatment of rhematogenous RD with PPV combined with cataract surgery, i.e., a complex procedure involving both anterior and posterior segment manipulations.

Digital 3D "Heads-up" Cataract Surgery: Safety Profile and Comparison with the Conventional Microscope System

PURPOSE

The aim of this study was to compare the complication rates between surgery performed using digital heads-up 3D system (3D group) and a conventional binocular microscope-based system (BM group) in a large series of cataract operations performed by the same surgeon.

METHODS

This retrospective analysis included a consecutive series of 2,000 cataract operations. The 3D group included n = 1,000 operations performed immediately following the introduction of a 3D system (Alcon Ngenuity). For comparison, the last n = 1,000 operations performed with a binocular microscope were included in the BM group. The 3D system was adapted to the existing microscope so that the microscope optics remained unchanged. The In both groups, the surgical techniques used were either phacoemulsification or femtosecond laser cataract surgery. Complications were recorded and analyzed retrospectively.

RESULTS

The proportion of femto-laser cataract operations was 19.8% in the 3D group and 18.6% in the BM group. Capsule rupture occurred in 10 eyes (3D: n = 4 (0.4%), anterior vitrectomy: n = 2, pars plana vitrectomy: n = 1; BM: n = 6 cases (0.6%), anterior vitrectomy: n = 4, pars plana vitrectomy: n = 1). A short-term iris prolapse occurred in 3 eyes (3D: n = 2, BM: n = 1). Zonulolysis occurred in 2 eyes (3D: n = 1, BM: n = 1). Overall, there was no statistically significant difference between the two groups (p > 0.5). There was no significant increase in the duration of surgery following the switch to the 3D technique.

CONCLUSION

In a large series of 2000 eyes, there was no significant difference between 3D and BM surgery in terms of the safety profile during cataract surgery. 3D surgery can, therefore, be used for cataract operations without additional risk.

Three-dimensional heads-up surgery in ab-interno trabeculotomy: Image processing-assisted trabeculotomy

Purpose

We compared the visibility and surgeon posture between image-processing-assisted trabeculotomy (IP-LOT) using the NGENUITY^® 3D visual system and conventional microsurgery (microscope-assisted trabeculotomy; MS-LOT).

Methods

IP-LOT was performed for five pig eyes. The visibility of the trabecular mesh work was evaluated on images of the trabecular mesh work and the posterior surface of the cornea (Cor) obtained under three different conditions. Images were then analyzed using ImageJ^® to measure differences in luminance between the trabecular mesh work and Cor. IP-LOT was also performed for eleven human eyes, and the data were analyzed using the same approach as that used for the pig eyes. The length from the surgeon’s abdomen to the operative eye (working distance) during MS-LOT and IP-LOT was measured for 12 different surgeons and compared to evaluate surgeon posture.

Results

Image processing significantly increased the difference in luminance between the trabecular mesh work and Cor in both pig and human eyes (p < 0.05). Moreover, the working distance in IP-LOT was significantly shorter than that in MS-LOT (p < 0.05).

Conclusion

Our findings suggest that the NGENUITY^® 3D visual system provides better trabecular mesh work visibility than a normal microscope in conventional surgical methods, and it allows surgeons to operate without moving far from the operative eye.

Cognitive workload, complications and visual outcomes of phacoemulsification cataract surgery: Three-dimensional versus conventional microscope

PURPOSE

To compare the surgical workload, complications, and visual outcomes using the three-dimensional visualization system with the conventional microscope in phacoemulsification cataract surgery.

DESIGN

Prospective, non-randomized, open-label interventional study.

METHODS

All patients underwent phacoemulsification cataract surgery using the three-dimensional visualization system or conventional microscope.

RESULTS

Of the 203 eyes, 80 underwent surgery with the three-dimensional system while 123 underwent with the conventional microscope. No difference was noted in the total surgical duration, complication rates, and visual outcomes between the two groups. However, capsulorhexis was significantly faster using the conventional microscope while posterior chamber intraocular lens insertion was quicker using the three-dimensional system. In terms of cognitive workload comparison, no difference was seen in the surgeons' heart rate, oxygen saturation levels, and surgery task load index total workload score and workload score for all six dimensions of the questionnaire, between the three-dimensional system and conventional microscope groups. As compared to baseline, the heart rate increased significantly during all surgical steps and at the end in both groups. When compared to baseline, the oxygen saturation levels were significantly raised during capsulorhexis, irrigation, and aspiration and posterior chamber intraocular lens insertion and at the end of the surgery in the three-dimensional group and during incision and at the end of the surgery in the conventional microscope group.

CONCLUSIONS

The duration of surgery, complications, and visual acuity outcomes remain unaffected while performing phacoemulsification cataract surgeries with the three-dimensional viewing system when compared to the conventional microscopes. Moreover, the surgeons' cognitive workload too remains unaffected while utilizing this revolutionary three-dimensional surgical technology.

Early corneal pachymetry maps after cataract surgery and influence of 3D digital visualization system in minimizing corneal oedema

PURPOSE

To describe the early topography of corneal swelling occurring after cataract surgery and to evaluate the impact of the three-dimensional (3D) digital visualization system in minimizing corneal oedema.

METHODS

Prospective observational, single-centre, consecutive case series of 134 patients undergoing cataract surgery performed by the same surgeon, with either 3D or conventional visualization systems. Eyes were assigned to two groups based on their anterior chamber depth (group ACD ≤3 mm and group ACD >3 mm). Optical coherence tomography was performed to evaluate postoperative corneal swelling.

RESULTS

Three corneal swelling profiles were identified on the first postoperative day type 1, limited corneal oedema near peripheral corneal incisions; type 2, dome-shaped corneal swelling spreading from the principal corneal incision and reaching the paracentral cornea; type 3, continuous oedema spreading from the principal incision to central cornea, with a generalized oedema predominating in the upper part of the cornea. On the first day after surgery, in group ACD ≤3 mm, visual acuity was significantly better in patients undergoing surgery with 3D visualization (0.023 vs 0.072 logMar, p = 0.014) with reduced central corneal thickening 17.3 µm (±3.2) in comparison with conventional visualization 44.0 µm (±9.3) (p = 0.0082). In group ACD >3 mm, no significant association was found between the use of the 3D system and pachymetry changes and early visual rehabilitation. On day 21 after surgery, no significant differences in corneal pachymetry values were observed between the two surgical approaches in both groups.

CONCLUSIONS

We describe early postoperative corneal map profiles providing insight into the pathogenesis of postoperative corneal swelling and possible prevention strategies. By improving visualization of the narrow surgical space in patients with shallow anterior chambers, the 3D system could help to minimize postoperative corneal oedema.

Initial experience with three-dimensional heads-up display system for cataract surgery - A comparative study

Purpose:

To compare the complication rates, surgical time and learning curve using the 3-D Heads up display system in comparison with the conventional microscope for routine cataract surgery.

Methods:

Consecutive consenting adults with uncomplicated cataract were offered phacoemulsification using the 3-D Heads up display system (ARTEVO 800 Carl Zeiss Meditec) or the conventional microscope (Zeiss Lumera 700) by two experienced surgeons. Surgical time, measured from start of corneal incision to removal of microscope from the surgical field and complication rates were compared between the groups.

Results:

Of the 343 eyes enrolled, 100 (29%) underwent surgery using the 3-D Heads up display system. The surgical time for 3-D Heads up display system was significantly higher in the 3-D group (8.4 ± 2.1 vs. 6.5 ± 1.8 minutes, P < 0.001). There were no group differences in surgical complications (2% in 3-D vs. 2.5% in conventional microscope, P = 0.28). Comparing across 4 quartiles within the 3-D group, the mean surgical time was slightly higher during the 1^st quartile (n = 25, 9.1 ± 1.9 minutes) compared to the last quartile (n = 25, 8.2 ± 1.9 minutes) (p = 0.17). Complications in the 3-D group occurred only in the initial 50% of cases. Seven (7%) cases in the 3-D group were converted to conventional binocular microscope of which 3 each were due to difficulty in depth perception and low illumination while one was due to intraoperative pupillary constriction.

Conclusion:

Phacoemulsification with the 3-D Heads up display system takes longer time but offers excellent visualization, ergonomics and safety compared to conventional microscopes. Experienced surgeons should be able to adapt easily after their first 50 surgeries.

Three-Dimensional Heads-up Cataract Surgery Using Femtosecond Laser: Efficiency, Efficacy, Safety, and Medical Education-A Randomized Clinical Trial

Purpose

To compare the efficiency, efficacy, and safety, as well as the educational value, of heads-up (three-dimensional visualization system–assisted) and traditional microscopic cataract surgery.

Methods

This randomized noninferiority trial enrolled 242 eyes of 201 patients who received femtosecond laser-assisted cataract surgery. The questionnaire study enrolled 26 medical interns and 39 medical students. Patients received surgery under either a three-dimensional visualization system (3D group, 117 eyes) or traditional microscope (TM group, 125 eyes) after random allocation. The primary outcome was surgical time. The noninferiority margin of surgical time was 60 seconds. Secondary outcomes included ultrasound power, phacoemulsification time, visual acuity, intraocular pressure, endothelial cell density, central corneal thickness, complications, and observer satisfaction scores for surgical procedures.

Results

Surgical time was 462.03 ± 80.36 seconds in the 3D group and 452.13 ± 76.63 seconds in the TM group (difference 9.90 seconds; 95% CI, –9.98 to 29.78; P = 0.365). Visual acuity and other perioperative parameters were comparable between the 3D group and the TM group (all P > 0.05). Incidences of both intraoperative and postoperative complications were low and not statistically different between groups (all P > 0.05). Across all observers, 3D surgery was superior to TM surgery for improving the degree of satisfaction (all P < 0.001).

Conclusions

The surgical efficiency of heads-up cataract surgery is not inferior to traditional microscopic surgery. Both methods achieved similar efficacy and safety outcomes. Moreover, heads-up cataract surgery showed a significant advantage in medical education.

Translational Relevance

Our findings show that heads-up cataract surgery has comparable efficiency, efficacy, and safety, as well as superior medical educational value, to TM surgery, which lays the foundation for promoting and popularizing this technology.

Efficacy of 3D digital visualization in minimizing coaxial illumination and phototoxic potential in cataract surgery: pilot study

PURPOSE

To compare the coaxial light intensity required during cataract surgery and rate of postoperative visual recovery, with surgical visualization achieved with a traditional analog operating microscope compared with a 3D digital visualization system.

SETTING

Weill Cornell Medical Center, New York Presbyterian Hospital, New York, New York.

DESIGN

Retrospective, consecutive, single-surgeon series.

METHODS

Patients undergoing femtosecond laser-assisted cataract surgery were retrospectively grouped into either: (1) visualization using the binoculars of a standard operating microscope (traditional group) or (2) visualization using a 3D digital visualization system affixed to the same operating microscope (digital group). Note was made in each case of light intensity used, light exposure time, intraoperative and/or postoperative complications, and postoperative visual acuities.

RESULTS

The study comprised 24 eyes in the traditional group and 27 eyes in the digital group. There were no intraoperative or postoperative complications in either group and no difference in mean light exposure time, but the mean light intensity used in the digital group was significantly less (18.5% ± 1.5%) than that in the traditional group (43.3% ± 3.7%; P < .001). Furthermore, the digital group achieved a postoperative day 1 visual acuity that was within 2 lines of the postoperative month 1 visual acuity a greater percentage of time than that in the traditional group (81.5% of eyes vs 54.2% of eyes; P = .04).

CONCLUSIONS

Light intensity was significantly decreased in patients who underwent cataract surgery assisted by the 3D digital visualization platform without an increase in complications or surgical time and possibly with a faster postoperative visual recovery.

Digitally assisted three-dimensional surgery - Beyond vitreous

Purpose:

The aim of this study was to evaluate the application and safety of three-dimensional (3D) visualization system in varied anterior segment procedures and Scleral Buckle.

Methods:

This was a prospective observational study of 313 eyes. Patients undergoing phacoemulsification (PE) with intraocular lens (IOL), trabeculectomies, glaucoma triple procedure (GTP), scleral fixated (SF) IOL, and scleral buckle (SB) were included in the study. Cases were randomly distributed in 3D visualization system (learning and post-learning phase) and conventional microscope group. Parameters studied were complications (intraoperative and early postoperative), surgical outcomes, and surgeon’s perspective on various parameters (through a validated questionnaire) like surgical time, time lag, learning curve, ease of doing various steps and its value as an educational tool, for both groups [Questionnaires 1 and 2].

Results:

Complications rates were not different in two groups. Surgical outcomes (anatomical and physiological) were similar in both the groups. Mean duration of surgery in PE+IOL, Trabeculectomy, GTP in learning stage by 3D was significantly higher than Microscope, which became insignificant in postlearning stage. For, SB and SFIOL, duration between two groups were insignificantly different. There was significant learning struggle in PE+IOL, SB, and Trabeculectomy. Image resolution, depth perception, illumination and postural comfort was graded higher for 3D surgery across the stages. Time lag, poor color contrast, and field of view were appreciated during the learning stage. Educational relevance of 3D was higher, as appreciated by resident and nurses.

Conclusion:

3D surgery is as safe, faster, and predictable after initial learning struggle. Even in anterior segment procedure, no apparent lag was appreciated after learning curve.

Use of the heads-up NGENUITY 3D Visualization System for vitreoretinal surgery: a retrospective evaluation of outcomes in a French tertiary center

Heads-up three-dimensional (3D) surgical visualization systems allow ophthalmic surgeons to replace surgical microscope eyepieces with high-resolution stereoscopic cameras transmitting an image to a screen. We investigated the effectiveness and safety of the heads-up NGENUITY 3D Visualization System in a retrospective evaluation of 241 consecutive vitreoretinal surgeries performed by the same surgeon using conventional microscopy (CM group) over a 1-year period versus the NGENUITY System (3D group) over a consecutive 1-year period. We included for study vitreoretinal surgeries for treatment of retinal detachment (RD) (98 surgeries), macular hole (MH) (48 surgeries), or epiretinal membrane (ERM) (95 surgeries). A total of 138 and 103 eyes were divided into 3D and CM groups, respectively. We found no differences in 3-month postoperative rates of recurrence of RD (10% versus 18%, p = 0.42), MH closure (82% versus 88%, p = 0.69), or decrease in central macular thickness of ERMs (134 ± 188 µm versus 115 ± 105 µm, p = 0.57) between the 3D and CM groups, respectively. Surgery durations and visual prognosis were also similar between both groups. We consolidate that the NGENUITY System is comparable in terms of visual and anatomical outcomes, giving it perspectives for integration into future robotized intervention.

Can the Three-Dimensional Heads-Up Display Improve Ergonomics, Surgical Performance, and Ophthalmology Training Compared to Conventional Microscopy?

Purpose

To explore ophthalmic surgeons’ opinions regarding three-dimensional heads-up display (3D HUD) use and investigate musculoskeletal (MSK) complaints among ophthalmologists.

Methods

Physicians were invited to complete an online questionnaire. Musculoskeletal complaints and data of the HUD system use were correlated with demographic information. We explored surgeons’ feedback on image quality, depth perception, and the educational value of 3D microscopy.

Results

In this study, the prevalence of self-reported MSK pain was 82.6% (n=132). The pain started after joining ophthalmology practice and significantly improves on weekends and vacations. We found that the pain intensity in non-HUD users is higher than in HUD users, but this correlation was not statistically significant. Sixty-one (84.7%) of HUD system users were satisfied with depth perception, and 27 (37.5%) reported improvement in peripheral acuity. Thirty-seven (51.4%) of the participants believed they perform surgeries better through HUD; this was why most participants (83.3%) recommended its use in surgical training.

Conclusion

Heads-up display use provides more comfortable sitting positions for surgeons, superior depth perception, and serves as a better educational tool. We believe that adopting this technology may help improve career longevity and productivity.

3D Heads-Up Display vs. Standard Operating Microscope Vitrectomy for Rhegmatogenous Retinal Detachment

Purpose: To assess the efficacy and outcomes of 23-gauge vitreoretinal surgery for rhegmatogenous retinal detachment using a three-dimensional heads-up display (3D HUD) surgical platform as compared to a standard operating microscope (SOM) setting. Design: Retrospective cohort study. Participants: One hundred and forty consecutive eyes of 140 patients with primary retinal detachment. Methods: All eyes underwent 23-gauge pars plana vitrectomy for primary retinal detachment using either a 3D HUD (NGENUITY; Alcon Inc., Fort Worth, Texas, USA; n = 70 eyes) or a SOM setting (n = 70 eyes); in cases of significant cataract, additional phacoemulsification with intraocular lens (IOL) implantation was performed. Minimum follow-up was 2 months. Main Outcome Measures: Primary retinal reattachment rate, rate of proliferative vitreoretinopathy (PVR), best-corrected visual acuity (BCVA), and duration of surgery. Results: There were 70 eyes each in the 3D HUD and the SOM group. Both groups did not differ concerning age (p = 0.70), extent of retinal detachment (p = 0.07), number of retinal tears (p = 0.40), macular involvement (p = 0.99), and preoperative BCVA (p = 0.99). Postoperatively, 3D HUD and SOM were comparable concerning the primary retinal reattachment rate (88.6 vs. 94.3%; p = 0.37), the development of postoperative PVR (12.9% vs. 7.1%; p = 0.40) and final BCVA (0.26 ± 0.40 vs. 0.21 ± 0.38 logMAR; p = 0.99). Duration of surgery was significantly longer in the 3D HUD group (66.2 ± 16.5 vs. 61.2 ± 17.1 min; p = 0.04), an effect which however vanished after a "learning curve" of the first 35 eyes (p = 0.49). Conclusions: On par results to a conventional operating microscope can be achieved with a 3D HUD setting when performing 23-gauge vitreoretinal surgery for rhegmatogenous retinal detachment, including the primary retinal reattachment rate, the incidence of postoperative PVR and final BCVA. However, duration of surgery might initially be slightly longer with 3D HUD, suggesting the effect of a learning curve.

Heads-up Descemet Membrane Endothelial Keratoplasty Surgery: Feasibility, Surgical Duration, Complication Rates, and Comparison With a Conventional Microscope

PURPOSE

To assess the feasibility of Descemet membrane endothelial keratoplasty (DMEK) surgery using the glasses-assisted 3-dimensional (3D) display system NGENUITY (Alcon Laboratories, Fort Worth, TX) and to compare with standard DMEK surgery by using a conventional operating microscope.

METHODS

Twelve consecutive cases of DMEK surgery were performed using the glasses-assisted 3D display system NGENUITY (Alcon) and matched with similar cases performed by using the OPMI-Lumera 700 surgical microscope (Carl Zeiss Meditec, Jena, Germany) in this prospective cross-sectional study realized at the Rothschild Foundation, Paris, France. DMEK graft preparation time, graft unfolding time, time to perform the descemetorhexis (DM), and overall surgical time were recorded. Best corrected visual acuity, endothelial cell density of the donor tissue measured by specular microscopy, and the recipient's central corneal thickness were recorded preoperatively and again at 1 and 3 months postoperatively.

RESULTS

In the 3D group, time to perform the graft preparation, DM, and global surgical time were significantly higher in the 3D group than in the conventional groups (17 minutes 36 seconds ± 3 minutes 13 seconds and 14 minutes 50 seconds ± 1 minutes 28 seconds, P = 0.04; 6 minutes 18 seconds ± 2 minutes 30 seconds vs. 3 minutes 50 seconds ± 2 minutes 8 seconds, P = 0.03; and 31 minutes 30 seconds ± 6 minutes 10 seconds vs. 24 minutes 10 seconds ± 3 minutes 26 seconds, respectively, P = 0.05). The time to unfold the graft was higher, although not significantly so, in the 3D group compared with the conventional group (5 minutes 15 seconds ± 2 minutes 40 seconds vs. 4 minutes 40 seconds ± 2 minutes 25 seconds, P = 0.89). Mean central corneal thickness decreased about 168 ± 82 μm at 3 months after surgery in the 3D group and about 228 ± 123 μm in the conventional group without significant difference (P = 0.60). Best corrected visual acuity in the 3D group was 0.33 ± 0.32 LogMAR at 3 months after surgery with no significant differences found when compared with conventional surgery. The percent endothelial cell loss from preoperative at 3 months was 35% in the 3D group and 26% in the conventional group, respectively, with no significant difference (P > 0.05).

CONCLUSIONS

Performing DMEK surgery using a 3D display system is feasible; however, it is more challenging and the total surgical time is longer. This method would certainly be useful for instructional courses.

Utility Of Three-Dimensional Heads-Up Surgery In Cataract And Minimally Invasive Glaucoma Surgeries

Purpose

This study aimed to assess the utility of the three-dimensional (3D) heads-up visualization system for minimal incision cataract surgery (MICS) and minimally invasive glaucoma surgeries (MIGSs).

Methods

Toric intraocular lens (IOL) implantation with phacoemulsification and trabecular microbypass stent implantation in patients with cataract and open-angle glaucoma were performed using the heads-up 3D visualization system combined with surgical navigation rather than the conventional microscope.

Results

This procedure was found to have the following advantages: the ability to clearly observe the anterior chamber angle image without requiring frequent focus adjustment owing to the extended depth of field and emphasized stereoscopic effect provided by this system and maintain the surgeon’s posture.

Conclusion

The feasibility and comfort of this system are greater than those of the conventional microscopic for performing MICS and MIGS.

Updated chandelier illumination-assisted scleral buckling using 3D visualization system

PURPOSE

To assess the updated chandelier illumination-assisted scleral buckle procedures using a 3D visualization system.

SUBJECTS AND METHODS

We report a single-center, retrospective, consecutive surgical case series of 18 eyes of 16 patients that underwent scleral buckle procedures combining the use of chandelier endoillumination, a noncontact wide-angle viewing system, an anti-drying contact lens, and a recently developed 3D visualization system. The mean age of the patients was 30.2 years, and the mean follow-up time was 11.3 months.

RESULTS

Retinal reattachment was achieved after the first surgery in all cases. There were no cases that required conversion of the 3D visualization to a conventional microscopic view. This updated chandelier-assisted scleral buckle procedure was successfully performed without any intraoperative or postoperative complications, except for the occurrence of postoperative diplopia in one case in which a supplementary radial buckle was used for a deep tear.

CONCLUSION

The updated chandelier illumination-assisted scleral buckling surgery using a 3D visualization system appears to be a valuable and promising method for managing rhegmatogenous retinal detachment due to atrophic holes in lattice degeneration or ciliary tears in younger cases.