EyeWorld Asia-Pacific December 2020 Issue

REFRACTIVE 38 EWAP DECEMBER 2020 Yao Ke, MD Chief & Professor, Second Affiliated Hospital of Zhejiang University School of Medicine 88 Jiefang Road, Hangzhou, China xlren@zju.edu.cn ASIA-PACIFIC PERSPECTIVES I agreed that heads-up surgery offers numerous advantages for surgeons, patients, and trainees. For surgeons, the ergonomic design enables a stable body posture to relieve their musculoskeletal stress. A high magnification is available to surgeons without experiencing any discomfort or eyestrain under the same microscope magnification, thereby relieving visual fatigue. For patients, the decreased illumination may reduce phototoxicity risk. For trainees, the immersive experience helps them to observe more details and improve intraoperative teaching procedures. Moreover, with the development of 5G data transmission and virtual reality technology, heads-up technology will aid ophthalmologists in real- time distance learning, which is vital for the spread of advanced surgical technology and assistance to underdeveloped areas. I first experimented with heads-up technology using the NGENUITY system (Alcon) and have also used the NCVideo3D visualization system (NewComm). For about a year, I have been using the NCVideo3D visualization system. The system comprises a 55-inch LCD monitor with a 4K LMD-X550TC display (Sony). Both heads-up path and microscope eyepiece are available for observation and can be switched as needed. I still like to use the traditional microscope in some cases such as excessive hydrops in the eye socket or corneal nebula that may lead to enhanced reflection on the 3D screen. Hence, compared to systems that only retain the heads-up path but cover the microscopic eyepiece, I prefer the NCVideo3D visualization system. In our recent randomized clinical trial (submitted in July 2020), 117 eyes of heads-up cataract surgery and 125 eyes of traditional microscopic cataract surgery were included. We assessed the surgical time, ultrasound power, absolute and effective phaco time, visual acuity, IOP, ECD, CCT, and perioperative complications. Our clinical practice showed that both surgeries achieved similar efficiency, efficacy, and safety outcomes. We also conducted a questionnaire study, enrolling 26 residents and 39 interns. Across all observers, heads-up surgery was superior to traditional microscopic surgery for improving the degree of satisfaction, especially in terms of depth of field and educational value. Editors’ note: Prof. Yao declared no conflicting interests. sophisticated image processing system that eliminates any lag. “Most surgeons are not noticing any lag or loss of contrast or resolution when they operate through the current generation 3D systems,” he said. Dr. Weinstock also called the ergonomics of heads-up technology “a whole game changer.” Study after study has been done, not just in ophthalmology, showing that the risk of work-related injury from microscopes is huge, he said, adding that 50–70% of microscopic surgeons at some point will suffer from acute or chronic back or neck injury relating to the position they’re in from operating for a long time. “When a surgeon is operating, they’re frozen in one position,” he said, which can cause stiffness and the potential for the surgeon to lose concentration/focus. Dr. Weinstock said comfort when you operate will allow you to operate longer, extend your career, and take less time off of work due to injuries. In addition, the ability to operate in that position may lead to less surgical complications because you’re more comfortable, he said. Dr. Ganesh commented that the heads-up technology offers the surgeon the option to operate while standing. He noted that sometimes a patient may have difficulty lying flat, and with this technology, he has performed surgery where the patient is essentially sitting upright. When asked about the possibility of converting during surgery from the heads-up display to the traditional microscope, Dr. Weinstock said it’s possible, but he no longer finds it necessary. When the heads-up technology was newer, and the resolution was not as high and the quality of the image not as good, Dr. Weinstock used to have a beam splitter and could switch back and forth. “But in the current generation, when surgeons switch over to this, you can dive right in and take the oculars off and put the camera on,” he said. “Once you get used to it, you don’t go back.” Dr. Weinstock added that guidance systems and overlays can also be used with this heads-up technology, though he doesn’t think these have evolved to their full potential yet in conjunction with this technology. “They’re all good, and they all have their roles, and I think that’s a lot of surgeon preference. I think that type of technology will continue to improve and be built into these scopes,” he said. Dr. Ganesh did note some potential disadvantages of heads-up technology, mainly the amount of space it occupies in the OR. He added that he also likes to still use the traditional microscope for suturing, as he finds this is a slightly better and faster method. Introducing the technology into the OR Dr. Weinstock touted the benefits of heads-up technology for surgical staff. “It’s amazing for scrub techs to be able to see the sensors in the 3D camera that capture the image coming from the microscope, he said. The optics of the microscope are still used as a light source, but instead of going into your eyes, it’s going into a sensor, he said. These have evolved up to 4K sensors or higher, which is processed quickly by a