March 2020


Illuminating intraoperative technologies
3D viewing systems: Is it time to upgrade your microscopy?

by Liz Hillman Editorial Co-Director

Dr. Rubenstein operates with the NGENUITY Visualization System.

Everyone in the OR wearing 3D glasses sees the same view as the surgeon using 3D digital microscopy.
Source: Jonathan Rubenstein, MD

“It’s a great adjunct for
education, is an amazing experience to operate with, and provides a fun factor for people who like new
—Jonathan Rubenstein, MD


Since January 2019, Jonathan Rubenstein, MD, has tried to use 3D, digital microscopy almost exclusively for his cataract and anterior segment cases.
First and foremost, Dr. Rubenstein sees a value in 3D viewing systems for teaching.
“Residents and anyone else in the room—whether it’s residents, medical students, OR staff, nurses, or technicians—can see what’s going on, have the same view I have and understand the surgery a little better,” he said. “For nurses and technicians, it makes them more interested in eye surgery and it also makes them better assistants for me and better help for the patient.”
He also likes it because, as he put it, it’s fun.
“New technology always makes surgery a little fresher and more exciting,” he said. “You are learning a new perspective about the eye and about surgery because you are using a different visualization system.”
The transition from a traditional operating microscope to surgery off a screen isn’t as awkward as you might think, Dr. Rubenstein said.
“In my first case using a 3D system, adapting to it wasn’t much of a problem at all, and now I like it the more I use it. Right off the bat it was not a hard transition,” he said.
The NGENUITY 3D Visualization System (Alcon), the system Dr. Rubenstein uses, consists of a 3D stereoscopic, high-definition digital camera that’s mounted on the surgical microscope. The live imaging is broadcast on a large, high-definition screen in the operating room. Everyone in the room wears 3D glasses and the surgeon operates while looking at the screen. Other 3D visualization systems include TrueVision 3D (Leica Microsystems) and ARTEVO 800 (Carl Zeiss Meditec).
Christopher Riemann, MD, a retina specialist who published the first series of screen-based vitreoretinal surgery in 2011, also cited the teaching benefits of digital microscopy.1 One of these is lower risk for phototoxicity.
Dr. Riemann, who has been doing screen-based vitreoretinal surgery almost exclusively since 2014, said he uses 35% illumination with the CONSTELLATION Vision System (Alcon) when operating with a traditional microscope, compared to 5–15% illumination when using digital microscopy. “Lower phototoxicity risk means residents and fellows, who might take longer, get to do more in surgery,” Dr. Riemann said.
The teaching experience is also better for the attending and the trainee. “It is an up close and personal experience, and a lot of fellows get nervous when operating with staff. For me, being able to sit back, not be in pain while awkwardly straining to look through assistant oculars, looking at the same image, sitting 3–4 feet behind them … it makes for a much better teaching experience,” Dr. Riemann said.
In any teaching situation, there will be times when the faculty member needs to step in and show the trainee what to do (or perhaps help them if things go awry). With a typical operating microscope, this would require the student to pull back, for the instructor to move into position, and adjust the microscope to their personal pupillary diameter and instrument myopia settings. This, Dr. Riemann said, can take up 30–45 seconds.
“In an eye where something isn’t going well, 45 seconds is a long time,” he said. “But [with a digital screen] I can jump in in about 10 seconds.”
The screen itself is like a “digital surgical cockpit,” Dr. Riemann said. An overlay of machine parameters gives the surgeon vital information while allowing them to keep their eyes on the surgical field.
“Instead of having to ask the tech, ‘What is my actual suction right now?’ I can look at the screen. It’s right there, without a head turn away from the surgical field,” he said.
Shannon Wong, MD, and Dr. Rubenstein also touted the information that could be available on the screen.
“The potential to have image overlays for astigmatism management (e.g., arcuate incision placement), capsulorhexis diameter, intraoperative aberrometry, OCT, or topography would be useful applications for this technology,” Dr. Wong said.
“It gives you the potential opportunity to have all the applications you now visualize on separate screens alternatively project on one big screen. They haven’t totally coordinated that … but I think that this is what industry will end up creating,” Dr. Rubenstein said.
The doctors are split on the ergonomic benefits of this “heads-up” surgery. Dr. Riemann said 3D microscopy probably added 10 years to his surgical career by reducing his back pain.
Dr. Rubenstein, in contrast, thinks the ergonomic benefit of 3D microscopy is “overblown.” He said the visualization is projected somewhat off to the side, requiring the surgeon to turn their head or body slightly to visualize the big screen. He also has noticed he adapts a more relaxed posture when he uses the heads-up system.
“I find when I’m working through the NGENUITY, I’m slouching because I’m sitting back like I’m in an easy chair. I’m not sure how good that is either. It’s more comfortable, but it’s not the correct posture to be in when you’re operating. It is still better for you to maintain a good erect posture to facilitate the correct use of your arms and hands when you’re operating,” Dr. Rubenstein said.

Value of 3D depends on the procedure

Dr. Rubenstein said he sees more value for this technology as you work deeper in the eye. The 3D visualization while peeling fine membranes off the retina or performing vitrectomies, for example, “gives you great depth of focus, more than with a conventional microscope,” he said.
“When you are doing these deep procedures … you barely have to adjust your depth of focus,” he said.
Dr. Rubenstein said that 3D in cataract surgery offers good depth of focus.
“I’m not saying operating in 3D is superior to conventional microscopes for cataract surgery, but it’s probably as good as, and there are some things that are a bit better because of the increased depth of focus,” he said.
Dr. Rubenstein also uses NGENUITY for DMEK and DSEK procedures, though he acknowledged it does “not produce as much of a ‘wow’ factor as you get with the cataract surgery.” For true superficial corneal surgeries—corneal transplants, suturing on the ocular surface, pterygium, etc.—Dr. Rubenstein said he doesn’t think 3D microscopy is advantageous.
“When I do a regular corneal transplant surgery, I do not use it because I think the suturing with it is weird. … It slows me down a bit,” he said.

Final takeaways

Overall, Dr. Rubenstein said he thinks this technology shows the most value in an academic setting and for those who “are motivated by new technology.” It is a benefit to get everyone in the OR seeing what the surgeon is seeing, and there are other features that are nice for anterior segment surgeons to have, but they’re not necessary, he said.
“It’s a great adjunct for education, is an amazing experience to operate with, and provides a fun factor for people who like new technology. It is also a great tool for the OR staff and people in the operating room to help them understand what’s happening in surgery, but I’m not sure that it will completely replace conventional microscopes. I think the ergonomics factor is a plus-minus,” Dr. Rubenstein said.
Though Dr. Riemann sees utility of 3D digital microscopy in vitreoretinal surgery, he said the technology was originally intended for anterior segment surgeons. Surgeons can operate through media opacity better with a digital microscope vs. analog, Dr. Riemann said, because you can drop the light and reduce internal scatter. You can also negate refractive factors by increasing the depth of focus by closing the camera aperture, he added.
“One of the best signs that this technology is here to stay is that other companies are now entering this space,” Dr. Riemann said.

At a glance

• 3D digital microscopy has been making inroads in vitreoretinal and anterior segment surgery, but its visualization benefits might depend on the procedure you’re doing.
• Physicians agree on its value as a teaching tool, providing everyone in the OR with the same view as the surgeon.
• Improved ergonomics of this “heads-up” surgery have been touted, but some think that benefit is “overblown.”

About the doctors

Christopher Riemann, MD
Director of the Vitreoretinal Fellowship
Cincinnati Eye Institute and University of Cincinnati
Cincinnati, Ohio

Jonathan Rubenstein, MD
Deutsch Family Professor of Ophthalmology
Rush University Medical Center
Chicago, Illinois

Shannon Wong, MD
Austin Eye
Austin, Texas


1. Riemann CD. Machine vision and vitrectomy: three dimensional high definition (3DHD) video for surgical visualization in vitreoretinal surgery. Proc SPIE 7863. Stereoscopic Displays and Applications XXII. 78630K (2011).

Relevant disclosures

: Alcon, Leica Microsystems
Rubenstein: Alcon
Wong: None



3D viewing systems: Is it time to upgrade your microscopy? 3D viewing systems: Is it time to upgrade your microscopy?
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