The three-dimensional (3D) digitally assisted visualization systems (DAVSs) have introduced a new era in ophthalmic surgery. During the “heads-up surgery”, the surgeons perform their procedures using heads-up displays without leaning forward towards the eyepieces of a traditional operating microscope (TOM). Firstly, Weinstock employed it in cataract surgery. Then, Riemann has pioneered its use for vitreoretinal procedures, following further assessment by Eckardt and Paulo. Nowadays, ophthalmologists use them in surgery for strabismus, glaucoma, keratoplasty, and oculoplastics.
Figure 1. Top – Internal limiting membrane (ILM) peeling with brilliant blue dye and forceps. Ngenuity® (a) andArtevo® 800 (b) intraoperative 2D snapshotsshow fundus details of the ILM peeled zone onto the macula, optic disc, vessels, and posterior pole up to the mid periphery. Bottom – Phacoemulsification. Ngenuity® (c) and Artevo® 800 (d) intraoperative 2D snapshots reveal iris surface details, the anterior capsulorhexis contour, and the lens cortex. Microscope, vitrectomy machine, and DAVS setting parameters are shown in the screen corners
The Alcon Ngenuity® and the Zeiss Artevo® 800 are passive 3D DAVS, working through a four-step series: an image capturing by a 3D high-definition image acquisition system; image processing by an ultra-high-speed, low-latency processor; image display into a 3D 4K-screen; and finally, visualization of stereoscopic optimized images through passive, circularly polarized 3D glasses (unlike active 3D systems). The whole team can experience an integrative surgical scenario in augmented reality. A 3D DAVS can also overlay real-time machine parameters, diagnostic tools, and patient data onto the live surgical screen. Moreover, operating in more relaxed stances may improve ergonomics.
Figure 2. Intraoperative optical coherence tomography (iOCT). The Ngenuity® (a) overlays the iOCT vertical and horizontal scans on the operative field together with vitrectomy machine parameters – a full-thickness macular hole, treated with a subretinal human amniotic membrane graft (rolled hyperreflective line under the retina). The Artevo® 800 (b) splits the screen to display the iOCT scans and the operative field side by side – appearance after epiretinal membrane peeling, showing wrinkling of the inner retinal surface and loss of the foveal depression
Looking to the future, we expect these systems to integrate voice recognition command to adjust display parameters without manipulating on-screen buttons, keyboards, or machine pedals. In addition, the new machine fusion softwares could promptly highlight on screen problems related to infusions, pressures, tube connections, and patient vital signs. Intraoperative 3D angiography may prevent under- or over-treatment. Deep learning algorithms might optimize the white balance process and help apply the best color settings according to the surgeon´s preferences, procedure type, and specific fundus pigmentation . High-speed network connections might increase opportunities for remote education, virtual surgical collaboration, or even robotic-assisted surgery real-time worldwide. Finally, augmented reality elements overlaying instructions and clinical data on the operative field might improve maneuvers execution, surgical guidance, visualization, and skills transfer.
Rodolfo Lima