Lights-out Surgery for Strabismus Using a Heads-Up 3D Vision System

Three-Dimensional Heads-Up vs. Standard Operating Microscope for Cataract Surgery: A Systematic Review and Meta-Analysis

Background: The surgical time duration, the postoperative best-corrected visual acuity (BCVA), and the incidence rate of intraoperative complications, alongside the vision and posturing parameters, were estimated by systematic review and meta-analysis to compare the three-dimensional (3D) heads-up visualization system (HUVS) and standard operating microscope (SOM) in cataract surgery. Methods: A literature search was conducted using PubMed, Embase, and Scopus on 26 June 2022. The weighted mean difference (WMD) was used to present postoperative BCVA and the mean surgical time duration, whereas the risk ratio (RR) was used to present the incidence rate of intraoperative complications. Publication bias was evaluated with Egger’s test. The Cochrane Collaboration’s Tool for randomized clinical trials, the methodological index for non-randomized, and the Newcastle-Ottawa Scale were used to assess the risk of bias. The research has been registered with the PROSPERO database (identifier, CRD42022339186). Results: In the meta-analysis of five studies with 1021 participants, the pooled weighted mean difference (WMD) of the postoperative BCVA showed no significant difference between patients who underwent HUVS versus SOM cataract surgery (WMD = −0.01, 95% confidence interval (CI): −0.01 −0.02). In the meta-analysis of nine studies with 5505 participants, the pooled WMD of mean surgical time duration revealed no significant difference between patients who underwent HUVS versus SOM cataract surgery (WMD = 0.17, 95% CI: −0.43–0.76). In the meta-analysis of nine studies with 8609 participants, the pooled risk RR associated with intraoperative complications was 1.00 (95% CI, 1.00–1.01). Conclusions: 3D HUVS and SOM provide comparable surgical time duration, postoperative BCVA, and incidence rate of intraoperative complications.

Comparison of Three-Dimensional Surgical System Versus Binocular Microscope for Clear Corneal Incision in Cataract Surgery

INTRODUCTION

To compare surgical outcomes of 2.2 mm clear corneal incision (CCI) between a three-dimensional (3D) visualization system and traditional binocular microscope (BM) for phacoemulsification and intraocular lens implantation surgery.

METHODS

In this randomized controlled clinical study, 60 eyes with age-related cataracts were divided into two groups receiving cataract surgery using either a 3D vision system (n = 30 eyes) (3D group) or a binocular microscope (n = 30 eyes) (BM group). We recorded and statistically analyzed surgical parameters and pre- and postoperative ocular parameters. Primary outcomes included the change in endothelial cell density (ECD) and CCI architecture, and secondary outcomes comprised other ocular parameters and surgical parameters. All procedures complied with the tenets of the Declaration of Helsinki.

RESULTS

Of the 60 eyes randomly assigned between January 5, 2021, and May 9, 2021, 55 (26 eyes in the 3D group and 29 eyes in the BM group) were analyzed. The ECD loss rate was 8.1% in the 3D group and 12.3% in the BM group, but the difference was not statistically significant. Local detachment of Descemet's membrane was seen in 50% (13 eyes, 3D group) and 51.6% (15 eyes, BM group), wound gaping at the endothelial side in 15.4% (four eyes, 3D group) and 10.3% (four eyes, BM group), gaping at the epithelial side in 11.5% (three eyes, 3D group) and 6.9% (two eyes, BM group), and misalignment of the incision in 3.4% (one eye, BM group) 1 day after surgery. These abnormalities improved with time. There was no difference between the 3D group and BM group in terms of other ocular parameters or surgical parameters before and after surgery.

CONCLUSIONS

Using the 3D surgical system for phacoemulsification and IOL implantation surgery seems to result in similar ECD and CCI conditions as using a conventional binocular microscope.

TRIAL REGISTRATION

The protocol was registered on ClinicalTrials.gov (NCT04839250).

Effectiveness of the Heads-Up Surgery System for Retinal Surgery in a Patient with Severe Photophobia

Background

The reported features and effectiveness of heads-up surgery (HUS) for ophthalmic surgery include greater resolution, teaching, and significantly reduced endoillumination power.

Objective

To report how to care for severe intraoperative photophobia using the HUS system during bilateral rhegmatogenous retinal detachment (RD) surgery in a patient with severe photophobia.

Case Report

A man in his 50s, who had been followed up for photophobia and visual impairment underwent five ophthalmic surgeries for bilateral RD. In his early 40s, he had been referred to our hospital because of a complaint of bilateral visual impairment, including severe photophobia, approximately 2 years prior. His decimal best-corrected visual acuities were 0.7 and 0.6 in his right and left eyes, respectively. Optical coherence tomography showed diffuse thinning of the entire retinal layer in the macula of both eyes, which was considered to be a cause of the decrement of visual acuity and photophobia. Twelve years after his first visit, he noticed multiple floaters in his left eye. For RD excluding the macular area, we planned cataract and retinal surgery under retrobulbar anesthesia. However, as we could not continue retinal surgery after cataract surgery due to severe photophobia, we performed general anesthesia (GA) during the second surgery. Seventeen months after the surgery, he underwent the third surgery for RD in his right eye under GA. For RD recurring twice, we performed surgery with the HUS system under retrobulbar anesthesia for the fourth and fifth surgeries, which avoided photophobia due to the significantly reduced light stimulation of the HUS system.

Conclusion

Lower light intensity achieved by the HUS system enabled us to eliminate the patient’s intraoperative discomfort. Consequently, we could perform the surgery under local anesthesia in this patient with RD who complained of severe photophobia that required GA using a conventional surgical system.

Digitally assisted three-dimensional surgery - Beyond vitreous

Purpose:

The aim of this study was to evaluate the application and safety of three-dimensional (3D) visualization system in varied anterior segment procedures and Scleral Buckle.

Methods:

This was a prospective observational study of 313 eyes. Patients undergoing phacoemulsification (PE) with intraocular lens (IOL), trabeculectomies, glaucoma triple procedure (GTP), scleral fixated (SF) IOL, and scleral buckle (SB) were included in the study. Cases were randomly distributed in 3D visualization system (learning and post-learning phase) and conventional microscope group. Parameters studied were complications (intraoperative and early postoperative), surgical outcomes, and surgeon’s perspective on various parameters (through a validated questionnaire) like surgical time, time lag, learning curve, ease of doing various steps and its value as an educational tool, for both groups [Questionnaires 1 and 2].

Results:

Complications rates were not different in two groups. Surgical outcomes (anatomical and physiological) were similar in both the groups. Mean duration of surgery in PE+IOL, Trabeculectomy, GTP in learning stage by 3D was significantly higher than Microscope, which became insignificant in postlearning stage. For, SB and SFIOL, duration between two groups were insignificantly different. There was significant learning struggle in PE+IOL, SB, and Trabeculectomy. Image resolution, depth perception, illumination and postural comfort was graded higher for 3D surgery across the stages. Time lag, poor color contrast, and field of view were appreciated during the learning stage. Educational relevance of 3D was higher, as appreciated by resident and nurses.

Conclusion:

3D surgery is as safe, faster, and predictable after initial learning struggle. Even in anterior segment procedure, no apparent lag was appreciated after learning curve.

Use of the heads-up NGENUITY 3D Visualization System for vitreoretinal surgery: a retrospective evaluation of outcomes in a French tertiary center

Heads-up three-dimensional (3D) surgical visualization systems allow ophthalmic surgeons to replace surgical microscope eyepieces with high-resolution stereoscopic cameras transmitting an image to a screen. We investigated the effectiveness and safety of the heads-up NGENUITY 3D Visualization System in a retrospective evaluation of 241 consecutive vitreoretinal surgeries performed by the same surgeon using conventional microscopy (CM group) over a 1-year period versus the NGENUITY System (3D group) over a consecutive 1-year period. We included for study vitreoretinal surgeries for treatment of retinal detachment (RD) (98 surgeries), macular hole (MH) (48 surgeries), or epiretinal membrane (ERM) (95 surgeries). A total of 138 and 103 eyes were divided into 3D and CM groups, respectively. We found no differences in 3-month postoperative rates of recurrence of RD (10% versus 18%, p = 0.42), MH closure (82% versus 88%, p = 0.69), or decrease in central macular thickness of ERMs (134 ± 188 µm versus 115 ± 105 µm, p = 0.57) between the 3D and CM groups, respectively. Surgery durations and visual prognosis were also similar between both groups. We consolidate that the NGENUITY System is comparable in terms of visual and anatomical outcomes, giving it perspectives for integration into future robotized intervention.