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Do digital platforms for 3-D surgery offer advantages for the anterior segment surgeon?
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Great potential
I use this technology and see great possibilities in future developments. My department was one of the first to introduce the platform for 3-D heads-up surgery in a public hospital. I was extra cautious at the beginning, but this lasted only for the first three cataracts, and then I was perfectly at ease. With 3 weeks of experience, the surgical time was half a minute longer than the average time I need for standard cataract surgery. One potential drawback, which has put off several surgeons from using this technology, is latency, the 90-millisecond delay that is perceived more during anterior than posterior segment surgery. This is because hand movements are more rapid and mostly on the horizontal axis during cataract surgery, for instance. When your hands move mostly on the vertical axis, as in posterior segment surgery, you are less aware of latency. At the beginning, this gave me a little bit of anxiety, but the brain quickly adjusts and now I hardly notice it.
In my opinion, however, the true advantages of this technology lie in the possibility to integrate and superimpose other images. For cataract, the obvious ones are projection of the axis for toric IOL implantation or the coordinates for perfect centration of multifocal lenses, but also anterior segment OCT. This latter implementation will be of great advantage for any surgery of the angle as well as for secondary IOL fixation. We need some system upgrade to fully exploit these possibilities, but the future is already here. This would fill in the gap between diagnostics, which gives us all that wonderful digital imaging information, and the OR, where we close the door and leave it all behind, sitting at an optical microscope.
Vincenzo Ferrara, MD, is head of Biella City Hospital, Biella, Italy. Disclosure: Ferrara reports no relevant financial disclosures.
No advantage
Heads-up surgery has no advantages, but stereoscopic glasses might offer something more. I have assisted some retinal surgery performed with the 3-D platform, but to be honest I was not inspired to try it in corneal surgery. I found the position uncomfortable, and the images were not better than those we can see with the operating microscope. Three-D could perhaps help with checking the orientation of the Descemet roll during Descemet’s membrane endothelial keratoplasty, but that is about the only advantage I can imagine in our surgery.
The technology of surgical microscopes has reached such a high level of image quality and integration with other intelligence, video and imaging technologies that I do not feel the need to abandon them for something else. The ergonomics have also improved considerably, and my position during surgery is now more comfortable than it used to be. I would not be too keen on having to train my body to adjust to a completely different position during surgery.
If I have to imagine a possible change in the future, I would rather think of OCT images integrated in the microscope or stereoscopic glasses. They could lead, for instance, to full integration of the OCT intraoperatively, something that would be of great benefit to us as corneal surgeons. Real-time OCT would make us see the immediate effects of what we are doing, like the unfolding of the DMEK roll or the dissection plane during deep anterior lamellar keratoplasty, with no need to stop and see where you are with your instruments at that point.
Paolo Rama, MD, is head of the cornea unit, San Raffaele Hospital, Milan, Italy. Disclosure: Rama reports no relevant financial disclosures.