Heads-up 3-D visualization system offers similar safety, efficacy as traditional microscope

Sumit Garg, MD

Surgical positioning and ergonomics are daily struggles for surgeons. All too often surgeons stretch, extend and contort to get through surgical cases. While this is easier when we are younger, the more cases we do and the older we get, the harder this becomes. While there have been many innovations with respect to surgical guidance and intraoperative tools, the mainstay of our intraoperative imaging remains the surgical microscope with oculars. About a decade ago, we saw our first innovations with respect to heads-up 3-D intraoperative visualization. Early iterations of this technology required a microscope-mounted camera that had a noticeable delay, loss of illumination from the beam splitter and dependence on a large computer console in the operating room.

Heads-up 3-D intraoperative imaging has come a long way from its inception. With Alcon’s launch of its Ngenuity system, we now have a heads-up system that incorporates a 4K OLED monitor with no noticeable delay. The system has gained popularity for both anterior and posterior segment surgery. The big question with respect to heads-up imaging systems is whether they are as safe and efficient as traditional microscope viewing.

Weinstock and colleagues present their retrospective study comparing safety (posterior capsular tear and vitrectomy rates) and efficiency (surgical time) between traditional visualization and 3-D heads-up visualization. The study showed statistical equivalence in both the measured safety and efficiency parameters. As with any study, there were drawbacks. Namely, the study excluded cases that could be considered complex (for example, pseudoexfoliation, Fuchs’ endothelial dystrophy or prior surgery), toric IOL cases, as well as those that included ancillary testing (intraoperative aberrometry). Additionally, this was a single-surgeon case series. Despite these limitations, the study results are promising.

At this year’s American Society of Cataract and Refractive Surgery meeting, Zeiss launched its own version of a 3-D heads-up imaging system that integrates intraoperative OCT, guidance and other enhancements to traditional viewing. With more and more of these types of systems on the horizon, we are looking at a shift in how will be approaching surgical visualization in years to come. Studies like the one presented here are helpful in changing the status quo, and I look forward to continued innovations in this space.