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 Table of Contents  
Year : 2021  |  Volume : 59  |  Issue : 4  |  Page : 329-330

Heads-up surgery in ophthalmology

Joint Editor of TJOSR, Vitreoretinal Services, JB Eye Hospital, Salem, Tamil Nadu, India

Date of Submission21-Nov-2021
Date of Decision22-Nov-2021
Date of Acceptance22-Nov-2021
Date of Web Publication21-Dec-2021

Correspondence Address:
Dr. V G Madanagopalan
JB Eye Hospital, Salem, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjosr.tjosr_179_21

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How to cite this article:
Madanagopalan V G. Heads-up surgery in ophthalmology. TNOA J Ophthalmic Sci Res 2021;59:329-30

How to cite this URL:
Madanagopalan V G. Heads-up surgery in ophthalmology. TNOA J Ophthalmic Sci Res [serial online] 2021 [cited 2022 Dec 10];59:329-30. Available from: https://www.tnoajosr.com/text.asp?2021/59/4/329/333163

When an ophthalmologist thinks of surgery, the operating microscope takes center stage. For the past three decades, peering into the surgical microscope has given surgeons the best possible view for tissue manipulation. The unique optics of surgical microscopes with binocular eyepieces had some distinct advantages when compared to the loupes that were in vogue in the preceding years. Depth perception, magnification, and field of view could be adjusted dynamically depending on the needs of a particular surgery or surgical step. As is wont with any technical device, surgeons felt that, despite the benefits offered, the binocular surgical microscope had scope for improvement.

Out of this need was born the heads-up ophthalmic surgical systems.[1] Among the many advantages offered, better ergonomics and surgeon comfort are most important. The prevalence of upper back and lower back pain among ophthalmic surgeons is as high as 30%–50%.[2] Heads-up systems have the potential to rectify this long-standing problem. The use of lower illumination and wider field of view with such systems are also important.[3] The need to constantly use an accommodative effort on the part of the surgeon is eliminated, and older surgeons benefit as their accommodative reserve is reduced.[1] Data from imaging devices that were captured in the preoperative evaluation can be superimposed on the large display screen to fine-tune surgical maneuvers. Integration of intraoperative optical coherence tomography scans helps with the identification of corneal endothelium, anterior capsule, posterior capsule, lens positions, and retinal membranes. The surgeon can gather all these data without looking away from the main display unit. Teaching is greatly aided by the implementation of heads-up surgery (HUS) as trainees, fellows, and assistants have an unhindered wide field perspective just as the surgeon does.[4] The assistant's scope has universally provided inferior visualization when compared to the surgeon's main scope.

Vitreoretinal surgeons were the first to explore the use of HUS, as augmented stereopsis and depth perception were especially suited to their work such as peeling of fine membranes and diabetic dissections.[5],[6] Moreover, unlike conventional optical microscopes that require the use of higher levels of illumination for visualization in the dark microenvironment at the back of the eye, HUS with their superior cameras allowed for work in lower illumination that could potentially limit light-induced retinal damage.[7],[8],[9] These advantages of visualization coupled with surgical comfort ensured that surgeons in other ophthalmic subspecialties caught on to the trend and began using HUS. It has to be mentioned that switching between 3D HUS and conventional eyepiece-assisted surgery is straightforward, and so clinicians were quick to try the new innovation. When surgeons switch between conventional microscopic viewing to HUS, there was a small learning curve which was noted to increase the duration of surgery.[10]

Altered color of tissues, difficulties in depth perception, substandard resolution in the periphery, less than satisfactory sharpness of an image, a small lag between surgical events and their display on screen, and the need to turn the head to one side to look at the display unit are often cited as difficulties by surgeons in using HUS. The need for larger floor space in the operating room to install the systems and the high costs are currently an impediment to the widespread adoption of this technology.[11]

In practice, the NGENUITY 3D system (Alcon, Fort Worth, TX, USA), ARTEVO 800 3D (Carl Zeiss Meditec, USA), Proveo 8 3D (Leica, Wetzlar, Germany), and TRUGLOW 3D (Appasamy Associates, Pondicherry, India) are the HUS systems available to ophthalmologists. Essentially, there are four components to 3D HUS. The crux is a high-dynamic range 3D camera that offers high resolution, excellent image contrast, and enhanced depth of focus. Next, a high-speed graphics processing unit is responsible for real-time integration of the stereoscopic images and providing clarity of the anatomical structures during precise microsurgery. A large (around 50–55 inch) immersive 3D display unit with 4k organic light-emitting diode ultra-high-definition screens is used for visualization of anatomic structures and overlaid imaging and/or technical data. Finally, the surgeon is required to wear 3D circular polarized glasses.

In conclusion, a logical progression to automation and extended reality taking up more responsibilities in the ophthalmic surgical domain is expected in the near future. Ensuing applications and subsequent cumulative developments will provide for robotic surgical interventions. Phasing out dependence on optical systems and introducing complete digital viewing is a long-awaited first step in this exciting journey.

  References Top

Kantor P, Matonti F, Varenne F, Sentis V, Pagot-Mathis V, Fournié P, et al. Use of the heads-up NGENUITY 3D visualization system for vitreoretinal surgery: A retrospective evaluation of outcomes in a French tertiary center. Sci Rep 2021;11:10031.  Back to cited text no. 1
Hyer JN, Lee RM, Chowdhury HR, Smith HB, Dhital A, Khandwala M. National survey of back & neck pain amongst consultant ophthalmologists in the United Kingdom. Int Ophthalmol 2015;35:769-75.  Back to cited text no. 2
Adam MK, Thornton S, Regillo CD, Park C, Ho AC, Hsu J. Minimal endoillumination levels and display luminous emittance during three-dimensional heads-up vitreoretinal surgery. Retina 2017;37:1746-9.  Back to cited text no. 3
Eckardt C, Paulo EB. Heads-up surgery for vitreoretinal procedures: An experimental and clinical study. Retina 2016;36:137-47.  Back to cited text no. 4
Zhang Z, Wang L, Wei Y, Fang D, Fan S, Zhang S. The preliminary experiences with three-dimensional heads-up display viewing system for vitreoretinal surgery under various status. Curr Eye Res 2019;44:102-9.  Back to cited text no. 5
Matsumoto CS, Shibuya M, Makita J, Shoji T, Ohno H, Shinoda K, et al. Heads-Up 3D surgery under low light intensity conditions: New high-sensitivity HD camera for ophthalmological microscopes. J Ophthalmol 2019;2019:5013463.  Back to cited text no. 6
Nariai Y, Horiguchi M, Mizuguchi T, Sakurai R, Tanikawa A. Comparison of microscopic illumination between a three-dimensional heads-up system and eyepiece in cataract surgery. Eur J Ophthalmol 2021;31:1817-21.  Back to cited text no. 7
Bawankule PK, Narnaware SH, Chakraborty M, Raje D, Phusate R, Gupta R, et al. Digitally assisted three-dimensional surgery – Beyond vitreous. Indian J Ophthalmol 2021;69:1793-800.  Back to cited text no. 8
[PUBMED]  [Full text]  
Ohno H. Utility of three-dimensional heads-up surgery in cataract and minimally invasive glaucoma surgeries. Clin Ophthalmol 2019;13:2071-3.  Back to cited text no. 9
Kelkar JA, Kelkar AS, Bolisetty M. Initial experience with three-dimensional heads-up display system for cataract surgery – A comparative study. Indian J Ophthalmol 2021;69:2304-9.  Back to cited text no. 10
[PUBMED]  [Full text]  
Agranat JS, Miller JB, Douglas VP, Douglas KA, Marmalidou A, Cunningham MA, et al. The scope of three-dimensional digital visualization systems in vitreoretinal surgery. Clin Ophthalmol 2019;13:2093-6.  Back to cited text no. 11


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