When you talk to Steve Charles, MD, FACS, FICS, of Charles Retina Institute in Germantown, TN, about heads-up eye surgery, he is quick to tell you two things: 1) “heads-up” is a misnomer, and 2) he loves the technology.

“Ophthalmic surgery is all ‘heads-up’ — with modern oculars, we haven’t been operating bent over a microscope for 25 years,” he points out, rejecting a moniker that he says implies the advantages of this technology are ergonomic. “The real reason for using a 3D camera system is that its image quality exceeds a purely optical operating scope. When I tried one of the latest systems in October 2016, I bought it out of my own pocket. Since then, I have used it exclusively for about 18 retina procedures a week.”

Pravin U. Dugel, MD, managing partner at Retinal Consultants of Arizona, and clinical professor at USC Roski Eye Institute, Keck School of Medicine, Los Angeles, agrees that although the technology is excellent, the “heads-up” tag has to go.

“I don’t like the terms ‘heads-up’ or ‘3D surgery’ at all because they just belittle the entire technology,” says Dugel, who has used a 3D camera system exclusively for 3 years. “This has nothing to do with my back or looking ‘heads-up’ at a 3D screen. To me, that’s all superfluous. This has everything to do with giving you better depth of field and visualization than the microscope today, and most importantly, digitizing images as a groundwork for informatics overlays tomorrow. This is an age of informatics, and I think these systems will revolutionize retinal surgery.”

These surgeons’ enthusiasm is typical of those who embrace 3D camera systems in the OR. Currently, two options are available: the Ngenuity 3D Visualization System (Alcon), and Sony 3D (Sony Medical). Here, users share the reasons behind their enthusiasm.

• Depth of focus. 3D camera systems for surgical microscopes provide greater depth of field than microscopes alone, which means that all depths, from foreground to background, are simultaneously in focus. Dr. Charles explains: “This gives us a better 3D experience, and as patients breathe deeply or move, the image remains in focus, so there is no pausing to re-focus the microscope.”
• Big-screen view. Instead of viewing the eye through the oculars of the surgical microscope, surgeons using 3D camera systems wear 3D glasses and watch a big-screen monitor mounted a few feet in front of them. The high-definition magnification is enormous, enabling surgeons to use their foveal vision to look around on the highly magnified image.
• Color adjustment. Because 3D camera systems provide digital imagery, surgeons have the power to adjust color to their advantage. Dr. Dugel opts to “remove the blood” before surgery to better see the structures he is targeting. Dr. Charles changes color gains during macular surgery, enhancing his ability to see faint brilliant blue stain as the rest of the image tints to a contrasting orange. “I can also turn up the red to see indocyanine green stain, which allows me to use a much weaker and less toxic amount,” he says. “Turning down the background noise of red reflex is helpful as well, making the vitreous become a more visible, bluish hue.”
• Enhanced surgical results. The makers of 3D camera systems don’t claim that the technology will deliver better outcomes, but in Dr. Charles’ experience, there are clinical advantages that may benefit patients. “With the depth of field always in focus, operating at a higher magnification, I work with greater ease and efficacy. For example, I am able to effectively peel the epithelial membrane in a more complete fashion without damaging the retina,” he explains. “I don’t adopt something because it’s shiny and new — I want to do a better job. There is no doubt in my mind that this is better.”
• Same/improved patient flow. Because a 3D camera system resides in the OR, it fits neatly into patient flow on surgery day. There is no additional time required. In fact, a system can actually save time by avoiding the need to refocus when patients move during the procedure. In addition, because everyone in the OR can see the screen, a system can help patient flow by keeping everyone on the same page.
• Team coordination. With a 3D camera system, everyone in the OR sees the same thing the surgeon sees. The nurse, scrub tech, anesthesiologist, and fellow see the full procedure and learn to anticipate the surgeon’s next move. The team is able to function more effectively as a coordinated unit.
  “Without prompting from me, the anesthesiologist sees how the patient is tolerating the procedure, whether additional anesthesia is required, and at which point it’s best to stop anesthesia to allow for a quicker recovery in post-op,” explains Michael C. Diesenhouse, MD, medical director of Catalina Surgery Center and Eye Associates of Tucson. “At the same time, a scrub tech anticipates which instruments to hand me or calls out to a nurse for medications that may be needed. A circulating nurse assesses the patient’s comfort level. Everyone becomes very familiar with the procedure and able to determine when and how they are needed.”
• Efficient data transfer and access. By digitizing the surgical images, surgeons gain opportunities to incorporate surgical data into real-time updates and access. As Dr. Charles explains, “I use my system to display the office EMR system and native imaging software (OCT, fundus photos, scanned drawings, and so on) using a VPN remote desktop connection. In this way, the surgeon is operating in a HIPAA compliant, password-protected patient record environment and can export what was actually done in surgery for accurate and timely EMR and billing updates, as well as to export still images and short video clips.”
• Recording and teaching. Because 3D camera systems are high-definition, videos produced for review or teaching are very valuable. In fact, Dr. Diesenhouse regularly uses videos to teach staff and colleagues. “The image quality is great, and the images are very valuable for staff education, as well as for capturing images for publication. Our system is wired to other screens in the practice as well, so when we want to teach other doctors, we can show live or recorded surgery on a large screen.”
• Future potential. According to Dr. Dugel, many advantages of 3D camera systems have yet to be realized, but he’s working on it. “Now we have a digitized image of surgery, and once we digitize an image, we can do whatever we want with it,” he says. “I envision these systems will provide the necessary link between digital diagnostic imaging and surgery. We look at fluorescein angiograms, OCTs, fundus photographs, and other images before surgery, but when we go into the OR, we leave all of them behind. We have nothing. I am working to close that loop between the clinic and the OR using my digital 3D system. I think the future lies in merging digital imagery to put all of our information before us, whenever we need it.” ■