OASC | TECHNOLOGY

Microsurgery in 3D

3D viewing systems help surgeons educate residents, staff and patients. They also deliver better presentations, and provide a big-screen view when needed.

By Erin Murphy, Contributing Editor

PHOTO COURTESY OF RICHARD MACKOOL, MD

The microscope, observer scope and integrated video camera are commonplace in eye surgery settings. Now, some surgeons are using a 3D surgical viewing system that displays the procedure on a 3D monitor in the operating room and records it for future 3D viewing. Surgeons who use these systems swear by the advantages of going from scope to screen, of videotaping surgeries and of doing it all in three dimensions instead of two.

Is 3D for you? To answer that question, consider how these surgeons are using 3D viewing systems and learn what they like about the technology.

Engaging People in the OR

Until recently, only you and one observer or assistanting surgeon viewing through a beam splitter/assistant scope were able to watch the surgery in three dimensions. With a 3D monitor, everyone can be in on the action.

Jacob J. Moore, MD, medical director of Coastal Bend Eye Center and Ambulatory Surgical Center in Corpus Christi, Texas, uses a Sony 3D system. “The 3D system takes true high-definition video through both of the microscope’s optical paths, presenting it in real time in the OR on a medical-grade 3D monitor as well as recording and storing the video. Instead of relying on an observer’s scope for one person, we can let anyone in the room watch on screen,” he explains.

Another Sony user, Richard Mackool, MD, director of the Mackool Eye Institute and Laser Center in Queens, N.Y., and professor of ophthalmology at New York University Medical Center, says his staff appreciates the system. “Nurses and technicians in the OR love the 3D monitor. Instead of standing there and handing me what I need, they can put on 3D glasses and get in the game. Cataract surgery is a fascinating procedure to watch, and following along keeps them interested and engaged.”

That inclusivity is important to Michael A. Saidel, MD, director of cornea service at the University of Chicago. He has been using the TrueVision 3D system (truevisionsys.com) for more than a year. “Although folks without glasses can still get an idea of what’s going on — the screen image just appears distorted — I like to have my scrub technician wear 3D glasses. Really, anyone who wants to watch in 3D can grab a pair, whether it’s the circulating technician or an anesthesiologist,” he says. “Residents benefit, too. The system’s greatest advantage is that it makes an excellent teaching tool for residents, and the 3D monitor allows more residents to watch without crowding around an observer scope.”

Teaching Residents (and Yourself)

Among the advantages of 3D viewing systems, training is paramount. Residents and other medical professionals get a simulator-style experience, rather than merely an observer’s view.

“The new viewing systems have stunning image quality that makes them superb for training physicians or ancillary medical personnel. If that’s a part of your work, this is the way to do it,” says Dr. Mackool. “The 3D view is absolutely better than what they get with current observer scopes, and there’s no limit to the number of people you can train inside or outside the OR with video.”

Dr. Mackool also uses 3D video to enhance his own work.

“I review videos for teaching purposes and edit them to present to colleagues, but I get a clinical advantage in reviewing the videos for my own education,” he explains. “The 3D video really makes me feel like I’m performing the surgery — I even find my hands going through the motions — there’s just no comparison to two-dimensional video. I find myself saying, Why didn’t he just do this? And it’s me! So I’ve actually improved the way I do certain things based on the 3D video. I also watch past videos to brush up [on a step in a surgery] when I have an extremely rare case on my schedule. The virtual practice is just about as effective as practicing a real procedure. When I go into the OR, I’m very clear on what I need to do and when I need to do it.”

Educating Patients

Understandably, many patients may not want to see a 3D video of their eye surgery, but surgeons find that the video does have a place in patient education.

“I share video with patients in select circumstances, such as when a patient is especially curious or when a complex case requires extra explanation,” Dr. Moore says. “For example, when I had to sew in a patient’s IOL, the lens wasn’t perfectly centered, causing some glare at the edge. We discussed the possibility of revising the positioning. The 3D video helped the patient see that this would be a technically demanding surgery, which may never have created a perfect outcome. She realized that she had an optimal situation for her eyes and passed on the second surgery.”

Dr. Mackool also finds that the high-resolution video helps him explain visual phenomena to patients in ways that diagnostic imaging devices can’t.

“If a patient has wrinkles in his cornea after LASIK, high-resolution 3D video of the cataract surgery shows that wrinkling — something slit lamp photography doesn’t have the resolution to capture. If that wrinkling impacts the patient’s vision, I can illustrate the situation, and the patient can then easily understand the problem and potential treatment,” he says.

Dr. Saidel agrees. “Fortunately, complications are rare events, but if you have a complication or some interesting development, video is useful, and 3D video is even more useful.”

“Two-dimensional video isn’t even half as good as 3D for teaching. 3D is so life-like and vivid — you feel like you’re having the experience.”

— Richard Mackool, MD, director of the Mackool Eye Institute and Laser Center in Queens, N.Y., and professor of ophthalmology at New York University Medical Center

Presenting to Colleagues

Your colleagues have sat in countless presentations with slides and videos. Dr. Saidel prefers that when the lights go down, the 3D glasses go on.

“If you want to get your point across, there’s no better way to do it than to use 3D video,” he says. “I taught a course at the last AAO meeting that was loaded with 3D video. It not only makes certain aspects of the surgery more educational, but it also makes the whole presentation more compelling. It requires a 3D projector and plenty of glasses, but the result is well worth it.”

Dr. Moore presents 3D video to colleagues to market his practice more effectively. “The system has practice-building potential for referrals,” he explains. “When I share cases with colleagues in 3D, I get a ‘wow factor’ that doesn’t occur with two-dimensional video. They get all of the depth information, so they can appreciate how little space we have in the lens capsule. It helps them understand our capabilities and ultimately increases the status of our practice.”

Relieving Your Neck

None of the surgeons interviewed for this article use a 3D viewing system for “heads-up” surgery. The consensus is that the 3D monitor complements, rather than replaces, the view through the microscope.

“It’s an interesting part-time heads-up device for certain procedures, especially when I’m using the TrueVision Refractive Cataract Toolset, which has an overlay for IOL placement,” says Dr. Saidel.

Nurses and technicians use a Sony 3D monitor to observe Dr. MacKool perform surgery.
PHOTO COURTESY OF RICHARD MACKOOL, MD

Dr. Mackool sees the downside of looking up. “It’s potentially better for surgeons ergonomically, but whatever might happen to a surgeon’s neck and shoulders has already happened to mine!” he says. “I also think that there are some negatives to a heads-up approach. If I look at the screen, it takes my eyes away from the patient, and my peripheral vision is not focused there. I might miss a patient twitch, move or get ready to move, and those things are very important.”

“I don’t do heads-up surgery with the monitor, but it may be possible sometime in the future,” Dr. Moore says. “I have looked up at the monitor during surgery, and I’d say the quality of the image on the monitor is equivalent to what I see through the microscope, without the limitations of the head’s ability to only rotate only a certain number of degrees. If the system is eventually tested and approved for heads-up surgery, I would be interested in trying that for my long-term health.”

Looking Ahead

Are we likely to see 3D video systems in more and more surgery centers? These doctors say yes, pointing to the systems’ strong educational value and ever-improving features.

“I think all video for education and lecturing will be 3D in a few years,” says Dr. Mackool. “Two-dimensional video isn’t even half as good as 3D for teaching. 3D is so lifelike and vivid — you feel like you’re having the experience.”

Dr. Moore also sees 3D video catching on. “I’m excited about the technology, and I think surgeons will see its potential for teaching, lecturing and practice building,” he says. “The systems are more accessible than ever, too. Any microscope that can attach a beam splitter to a v-mount camera can use the Sony, and they’re coming out with a new dedicated beam splitter so it’s easier to install and use. They’re always refining the product.”

“I think in the future, the next step is a high-information display, whether that’s in the microscope oculars or in a heads-up monitor. We’ll be able to look at multiple images simultaneously, along with demographic information and clinical data such as astigmatism, lens power or potential complications. We’ll see OCT overlays projected onto the eye,” Dr. Saidel says. “Current 3D technology is clearly a stepping stone to the next level. Like any technology, what we’re doing now isn’t what we’ll be doing in the future.” ■