Parag A. Majmudar, MD; Eva Liang, MD , 2025-05-05 14:52:00
Welcome to another edition of CEDARS/ASPENS Debates. CEDARS/ASPENS is a society of cornea, cataract and refractive surgery specialists, here to discuss some of the latest hot topics in ophthalmology.
The technology for three-dimensional heads-up surgery has been around for a while, but it has remained a niche procedure, embraced by a minority of surgeons. Like every other technology, 3D visualization systems were not perfect from the start. The main problem was latency, which may be only a fraction of a second but was a concern for many surgeons, in addition to a potentially inferior image quality and substantially higher cost as compared with a traditional microscope. Early users, on the other hand, immediately appreciated the advantages that this approach could offer in terms of wider field of view, ergonomics, and potential for training and education.
Where are we now? Have the improvements that the technology has undergone over the years converted skeptics? This is the debate we are proposing today, with Parag Majmudar, MD, and Eva Liang, MD, looking at 3D heads-up surgery from two very different angles.
Kenneth A. Beckman, MD, FACS
OSN CEDARS/ASPENS Debates Editor
It will be the future eventually
Every technology has a life cycle.
At the beginning, you have the early adopters, those who embrace innovation when they perceive that it has inherent advantages and spend time modifying it, adapting it and improving it so that it will eventually move to a wider use and become mainstream. That is how 3D heads-up surgical technology began about 10 years ago. Early users saw it as a great opportunity that could help in many different ways. The image quality was not so great, and there was a lag between hand movements and what we saw on the screen. That was disconcerting and discouraged quite a few of us, but we trusted the possibility that the technology would evolve through progressive improvements, eventually reaching its full potential.
There are different companies now working on 3D viewing systems. My experience is with the Alcon Ngenuity, which has gone through a number of iterations, improving to the point where the lag is down to maybe a millisecond and the quality of image is superb, better than what we can see with the naked eye through even the best top-level microscope. Surgeons can now visualize fine details with the Tissue Detail Mode, the Blue Boost Mode and the MIGS Mode for enhanced precision during minimally invasive glaucoma surgery. You get five times more extended field of vision as compared with the standard microscope, up to 48% more magnification and 42% increased depth resolution. You can customize the viewing experience. A further advantage of the large screen is that you can incorporate data from the patient’s exams: the biometric data, the IOL choice, the parameters for limbal relaxing incisions when required — everything at a glance in the same viewing platform. You cannot have these data projected into the ocular of a microscope because simply there is no room there.
Heads-up surgery also offers an overall more comfortable experience. You sit back with your back and neck in upright posture, while the microscope forces you to lean forward, causing spinal problem over the years. As surgeons, we have become more aware of how important ergonomics is for our long-term health and well-being. After a long day of operating, you feel the difference. You are more relaxed and physically better. When you are young, you may not appreciate the difference and recover fast from a day of bending forward toward the ocular of a microscope. But the effect is cumulative over 20 or 30 years.
Also, with the current systems, you still need to crane your neck a bit to see the TV screen. The next iterations will be wireless headsets, like a virtual reality headset, that will allow the surgeon even more ergonomic benefit as well as the ability to magnify the image and perform other manipulations with a simple nod of the head.
Comfort is improved also for the patient because of the lower light intensity that reduces the risk for retinal toxicity. We are now headed toward less anesthesia for patients and do not give them IV sedation all the time. So, when patients are awake, we want them to be comfortable, and that lower level of light makes a big difference. Despite low luminance, we can get great digitally enhanced images that help us perform surgery faster and more accurately.
Another significant advantage of heads-up is from the standpoint of teaching. With the traditional surgical setup, nobody in the operating room, including the people who are working there all the time, has any idea of what we actually do because they cannot see what we are doing. There is a 2D image on a TV screen, but from a 2D image you cannot get a sense of what is happening. With the 3D viewing system, everybody who wears 3D digital glasses can see exactly what the surgeon sees. It is a great way to educate your staff, as well as residents, fellows and colleagues who are visiting your office. We have an office-based surgery suite where we often welcome other referring doctors, optometrists and whoever wants to see how we work. They can see exactly what we are seeing, and it helps them understand what we do.
For all these reasons, I believe that 3D heads-up systems are going to be the future eventually. The big drawback, at least at present, is cost, but this is an investment that you are making for your well-being and patient comfort. Cost is likely to come down eventually, but that is definitely an issue that needs to be faced. We saw the same situation with femtosecond laser-assisted cataract surgery: Many people agreed that the technology was amazing but then backed off because of the cost. However, in comparison to laser cataract, this technology offers clear, significant benefits for both the patient and the surgeon, and I am sure it will become the way that most people operate. I think it is just a matter of breaking the paradigm.
- For more information:
- Parag Majmudar, MD, of Chicago Cornea Consultants, can be at pamajmudar@chicagocornea.com.
It is not for everyone
I am comfortable with our traditional microscope and do not feel the need to switch to a different type of technology for my surgery.
The choice is personal because not everyone can easily adapt to 3D surgical systems. In my case, I have natural monovision, with myopia in one eye and close to plano in the other eye, and while I can easily adjust the scope to have the best vision, with 3D viewing systems, I have to wear my glasses and then the 3D glasses on top. For my Asian face, with a little nose, two glasses on top of each other are a bothersome and unstable contraption. In our profession, we are always trying to make people spectacle-free, and all of a sudden, I would have to wear two pairs of glasses to operate. It would honestly feel odd, and I do not think I would feel much different if I were plano and had to wear only the 3D glasses. I have also tried the Beyeonics One system (Beyeonics Vision), which I thought might be better for me because I could dial my correction into it, but I did not like having a big device on my head. I have not tried Apple Vision Pro, but I am sure I would not like to wear those goggles and headgear. I find all those alternative viewing systems rather awkward, and I would come up to the scope. Although I do see the advantages of 3D heads-up surgery, I do not think it is for everyone.
In addition, 3D viewing systems are expensive. For those of us who have more than one operating room in their practice, having to equip them all with 3D displays rather than traditional scopes would have an economic impact.
Another aspect that I do not like is that you operate in a dark room. I like my OR to be well lit to see everyone who is around me and communicate with them at a glance. In a dark room, communication is difficult and action is slower. My anesthesiologist and my staff are fast and efficient because they can see what they need to see to do what they need to do.
One of the advantages that is often mentioned with 3D heads-up surgery is better ergonomics. You have your head up, and this prevents back and neck pain. However, you can adopt the correct posture while doing traditional microscopic surgery because our scope has a lot of possibilities. It can be adjusted to limit neck flexion, and the binoculars can be brought forward toward you, allowing you to sit upright, head above shoulders. It also can be tilted so that you can sit a little further back. Novice surgeons tend to go up to the scope without taking the time to adjust it, but as time passes, we usually learn to take better care of ourselves. I have made a lot of little adjustments to my scope over the years, and now I am comfortable during surgery.
I admit that many of us do not want to switch to 3D surgery because there is a long-standing habit and acquaintance with the traditional scope. In our practice, we have four surgeons, and when I brought up the idea of demoing the heads-up display, no one was interested. Nobody wanted to try it. The younger generation might be more willing to try it, and I don’t know how many of them are familiar with it in their training program. The 3D systems are definitely a great asset for surgical training because everyone can see what the surgeon sees.
I would like to end with an anecdote that also raises the issue of how a switch to 3D viewing systems would not be feasible in some parts of the world. I was on a medical mission in Kenya a few years ago, and during surgery, the power went out. We were obviously using traditional scopes there, and there were three of them in the OR. One of my colleagues still had light because he had strapped his headlamp onto that microscope earlier in the day when the bulb had died. These are the things you can do with a traditional scope, while digital technologies would require an unaffordable amount of infrastructure.
- For more information:
- Eva Liang, MD, of Center for Sight in Las Vegas, can be reached at evaliang11@gmail.com.
Sources/Disclosures
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Source:
Expert Submission
Disclosures:
Liang reports consulting for Bausch + Lomb and Johnson & Johnson Vision. Majmudar reports consulting for Alcon and Carl Zeiss Meditec.
