Use of a Novel Beyeonics One Three-dimensional Head-mounted Digital Visualization Platform in Vitreoretinal surgeries.

BACKGROUND: Ophthalmic microscopes have been crucial in visualizing surgical fields, but their limitations in enhancing the surgical view through digital image processing have prompted the development of digital surgical microscopes. The Beyeonics One microscope, a novel digital microscope, offers ophthalmic surgeons a 3D visualization platform and an augmented reality (AR) surgical headset, potentially improving surgical decision-making and outcomes. While its initial use has been described in cataract and corneal surgeries, its application in vitreoretinal surgery remains relatively unexplored. METHODS: In this interventional case series, we collected data from the medical records of patients who underwent vitreoretinal surgery using the Beyeonics One 3D visualization platform at the Tel Aviv Medical Center. A total of 36 eyes from 36 subjects were included. Surgical techniques included retinal detachment surgeries and macular surgeries, performed by experienced surgeons. The surgical visualization was facilitated by the Beyeonics One 3D head-mounted display (HMD) platform. RESULTS: The procedures were uneventful, and none intra- or postoperative complications were reported, and surgeons did not experience any signal delay in the real-time video. DISCUSSION: The Beyeonics One microscope offers several potential advantages in vitreoretinal surgery, including digital image processing, enhanced depth perception through the 3D HMD platform, and hands-free image control using head gestures. While this study demonstrates the feasibility and safety of the Beyeonics One microscope, addressing limitations related to hazy views and optimizing image quality are crucial for consistent visualization.

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.

Real-life comparison of the viewing angle and the image quality of two commonly used viewing systems for vitreoretinal surgery

Background/aim: To compare the clinical use, image quality and viewing angle of a commonly used contact wide angle viewing (WAV) system (Advanced Visual Instruments (AVI) Panoramic Imaging Systems, NY, USA) with a commonly used noncontact WAV system (Leica RUV800, Leica Microsystems, Switzerland). Materials and methods: Images of 42 consecutively operated eyes were obtained with both systems at the same surgical stages and were compared for image quality using the Imatest Master 4.5.13 (Imatest LLC, Boulder, USA) software. The viewing angles of the images were calculated using the optic disc sizes measured from the OCT and infrared fundus images. The 68-degree AVI lens was compared with the 90-dioptre (D) Leica RUV800 lens, while the 130-degree AVI lens was compared with the 132-D Leica RUV800 lens. The surgical assistants were asked to grade the difficulty of holding the lens in place from 1 to 10, 1 being the easiest and 10 being the most difficult. Results: The contact system provided wider viewing angles with higher quality compared to the noncontact system both under fluid and air media. The difference was clinically significant in eyes with impaired corneal clarity, very high myopia, or small pupil. The difficulty of holding the lens in place ranged from 4 to 7, and decreased gradually with practice. Conclusions: Both WAV systems provided high image quality and adequate viewing angles in most cases. However, the contact system appeared to provide a superior image quality and/or a wider viewing angle in more challenging situations. The difficulty of holding the contact lens in place was found to be moderate.

Utility of digitally assisted vitreoretinal surgery systems (DAVS) for high-volume vitreoretinal surgery centre: a pilot study.

AIM: To compare the surgical experience and preferred imaging platform, between digitally assisted vitreoretinal surgery systems (DAVS) and analogue microscope (AM), for performing various surgical manoeuvres. MATERIAL AND METHODS: A questionnaire was used to evaluate the experience of surgeons who used DAVS for at least 6 months in the last 1 year. RESULTS: Twenty-three surgeons, including 12 fellows, answered the questionnaire. Eighty-two per cent of surgeons got accustomed to DAVS in <10 surgeries. The higher magnification provided by DAVS was perceived as helpful by 87.0% surgeons. Seventy-eight per cent surgeons felt that DAVS provided a bigger field of view. Colours displayed on DAVS appeared unnatural to 39.1%. Difficulty using three-dimensional glasses over spectacles, asthenopia and dry eye symptoms while using DAVS were faced by 17.4%, 17.4% and 21.7% surgeons, respectively. Difficulty in frequent switching between DAVS and AM was faced by 30.4% surgeons. Difficulty in depth perception, hand-eye coordination and performance anxiety while using DAVS was faced by 43.5%, 21.7 % and 30.4 % surgeons, respectively. Majority consultants did not have any imaging platform preference for most posterior segment procedures, while majority fellows preferred DAVS. Majority surgeons preferred AM for anterior segment procedures and complicated situations like small pupil, corneal oedema and surgical surprise(s). Once the surgeons became accustomed to DAVS, none of them had to shift back to AM during any case. CONCLUSION: It was easy to adapt to DAVS. DAVS was preferred for performing most posterior segment surgeries. Drawbacks like unnatural colours of the projected image and difficulty in performing anterior segment manoeuvres need to be addressed.

Lens capsular flap in the management of posterior retinal hole associated retinal detachment in high myopic eyes with previous internal limiting membrane peeling: 3 case reports.

RATIONALE: Managing retinal detachment due to posterior retinal holes is problematic since standard laser retinopexy or scleral buckling may be difficult to apply and may have brought serious complication. Another surgical method in treating posterior hole related retinal detachment is desired. PATIENT CONCERNS: Three high myopia patients with previous vitrectomy and membrane peeling history suffered from blurred vision and retinal detachment due to posterior pole retinal holes was diagnosed. DIAGNOSES: Patient diagnosed retinal detachment due to posterior retinal holes either as paracentral retinal breaks or macular hole from both indirect ophthalmoscope exam and fundus photography INTERVENTIONS:: The patient underwent lens capsular flap insertion into all the retinal holes, along with gas tamponade or silicone oil tamponade. No laser retinopexy was performed around the retinal holes. OUTCOMES: Of 3 included patients, 1 patient had insertion of the lens capsular flap, an incomplete air-fluid exchange, and 24% sulfur hexafluoride gas tamponade. The other 2 patients, after lens capsular flap insertion, had air-fluid exchange and subretinal fluid drainage with extrusion via soft needle through superior drainage retinotomy and silicon oil tamponade. The retinal holes of all eyes were sealed with retina attached postoperatively. LESSONS: Lens capsular flap is effective in sealing posterior retinal holes and treating the associated retinal detachment without the complication resulting from laser retinopexy, especially in eyes without sufficient internal limiting membrane (ILM) tissue due to previous ILM peeling.

The Preliminary Experiences with Three-Dimensional Heads-Up Display Viewing System for Vitreoretinal Surgery under Various Status.

Statement: The current article has not been published elsewhere and has not been submitted simultaneously for publication elsewhere. PURPOSE: To investigate the preliminary use of three-dimensional (3D) heads-up display (HUD) viewing system for vitreoretinal surgery under various status. MATERIALS AND METHODS: Nonrandomized case-control study. Consecutive cases to have vitreoretinal surgery under various status were prospectively recruited. Twenty-five-gauge vitrectomy platform and 3D viewing system were used. Main outcomes included: luminous emittance (lux) of endoillumination pipe, surgical duration, the surgeon and residents' preference and ergonomics. Consecutive patients to have vitreoretinal surgery with the conventional viewing system were recruited as control group following the same inclusion and exclusion criteria and underwent surgeries by the same surgeon with the same microscope and vitrectomy platform. RESULTS: Thirty-one patients (31 eyes; Group Study) and twenty-eight patients (28 eyes; Group Control) were included; without significantly statistical difference in terms of age, gender, main diagnosis, surgical duration, and difficulty rating between both groups (all P > 0.05). Lower endoillumination intensity was needed in Group Study than that in Group Control (10% vs. 35%; 598.7 ± 5.4 vs. 1913.0 ± 12.9 lux, P < 0.001). The surgeon and residents expressed overwhelming preference with the 3D system in both groups. Improved ergonomic was rated in Group Study (4.4 ± 0.8 vs. 3.2 ± 1.0, P < 0.001). Some intraoperative difficulties and discomforts appeared to the surgeon and assistants when using the 3D viewing system. CONCLUSION: Vitreoretinal surgery under various status can be well finished with the HUD platform by novice at the system. Main benefits included lower endoillumination intensity, enhanced users' preference, and improved ergonomics. Some further refinements of the system are expected.

RESOLUTION, DEPTH OF FIELD, AND PHYSICIAN SATISFACTION DURING DIGITALLY ASSISTED VITREORETINAL SURGERY.

PURPOSE: To evaluate depth of field, lateral resolution, and image quality of a heads-up 3D visualization system for vitreoretinal surgery using physician survey and optical measurement outcomes. METHODS: Depth of field and lateral resolution were compared between the standard ocular viewing system and the digital 3D system at ×5, ×13, and ×18 magnification by 6 retinal surgeons. Optical techniques were used as well as a survey of surgeon impression. Surgeon impression surveys were performed after 6 weeks of surgical use of the device. RESULTS: Physician questionnaire survey scores for depth of field at high magnification were better for the digital 3D system and equivalent for all other categories. Measured lateral resolution was 36.7 mm and 16.6 mm at ×5 magnification (P < 0.001), 14.3 mm and 6.4 mm at ×13 magnification (P < 0.001), and 9.8 mm and 4.2 mm (P < 0.001) at ×18 magnification for the digital 3D and oculars, respectively. Measured depth of field was 4.00 mm and 6.78 mm at ×5 magnification (P = 0.027), 0.72 mm and 0.86 mm at ×13 (P = 0.311), and 0.28 mm and 0.40 mm at ×18 magnification (P = 0.235) for the oculars and digital 3D, respectively. CONCLUSION: Lateral resolution of the digital 3D system was half that of the ocular viewing system and there was some improvement in depth of field with the digital system. Surgeon impression suggested that the digital system was superior when evaluating depth of field at high magnification.

Autonomous Positioning of Eye Surgical Robot Using the Tool Shadow and Kalman Filtering.

Vitreoretinal surgery is one of the most difficult surgical operations, even for experienced surgeons. Thus, a master-slave eye surgical robot has been developed to assist the surgeon in safely performing vitreoretinal surgeries; however, in the master-slave control, the robotic positioning accuracy depends on the surgeon's coordination skills. This paper proposes a new method of autonomous robotic positioning using the shadow of the surgical instrument. First, the microscope image is segmented into three regions-namely, a micropipette, its shadow, and the eye ground-using a Gaussian mixture model (GMM). The tips of the micropipette and its shadow are then extracted from the contour lines of the segmented regions. The micropipette is then autonomously moved down to the simulated eye ground until the distance between the tips of micropipette and its shadow in the microscopic image reaches a predefined threshold. To handle possible occlusions, the tip of the shadow is estimated using a Kalman filter. Experiments to evaluate the robotic positioning accuracy in the vertical direction were performed. The results show that the autonomous positioning using the Kalman filter enhanced the accuracy of robotic positioning.

Retinal Toxicity of Medical Devices Used during Vitreoretinal Surgery: A Critical Overview.

Retinal toxicity/biocompatibility of medical devices in direct contact with the retina is an important subject for clinicians and scientists. As these effects are not very frequent, there is also a relative lack of information for many clinicians. The past has taught us multiple times that there is a significant safety problem associated with severe loss of vision in affected patients. In this review, we want to classify medical products that are used in the back of the eye, describe recent examples of toxicity, critically reflect on the regulations that exist and suggest improvements that can be done to ensure patient safety without hindering innovation. METHODS: Critical review of the recent papers and personal experience of the authors in this issue. Medical devices used in the back of the eye and recent examples of toxicity are described, regulations that exist are critically reflected and improvements suggested that can ensure patient safety without hindering innovation. RESULTS: There is clear evidence of toxicity after intraocular surgery in any category. Some cytotoxic indirect methods have failed in detecting this toxicity. Some ISO rules do not seem appropriate. Postmarketing safety is missing. There is little data on this issue. CONCLUSIONS: The absence of a clear regulation of the production, purification and evaluation of the toxic effects of the medical devices supposes the possibility that products are not sufficiently safe to obtain the CE mark.

Intraoperative optical coherence tomography-compatible surgical instruments for real-time image-guided ophthalmic surgery.

Intraoperative optical coherence tomography (OCT) is a potentially transformational technology that is now commercially available to ophthalmic surgeons. Currently, the use of the technology is primarily limited to a 'stop and image' approach due to the lack of OCT compatibility with surgical instrumentation. In this report, we describe multiple OCT-compatible surgical instruments that were developed for various surgical needs, based on previous evaluation of potential surgical materials for optical features and physical properties. OCT-compatible instrumentation included two membrane scrapers, a surgical pick and vitreoretinal forceps. Imaging during in vitro and ex vivo-simulated surgical procedures demonstrated excellent visualisation of the instrument tip and of the tissue-instrument interaction. These OCT-compatible instruments may be a key component to the feasibility of real-time image-guided surgery with intraoperative OCT.

Importance of Light Filters in Modern Vitreoretinal Surgery: An Update of the Literature.

PURPOSE: Direct endobulbar illumination during vitreoretinal surgery causes light-induced retinal damage known as phototoxicity. Spectral filters have been proposed to eliminate hazardous wavelengths from the emission spectrum before entering the eye. The purpose of our paper is to review advances in vitreoretinal surgery, focusing on intraoperative light filters. METHODS: A PubMed and Medline database search was carried out using the terms "spectral filters" associated with "vitreoretinal surgery," "phototoxicity," and "vitrectomy." Original articles, reviews, and book chapters up to March 2017 were reviewed; a few select articles published before 2000 are included for historical purposes. Material from recent meeting presentations was also added. The preferred language for the reviewed literature was English. RESULTS: Spectral filters significantly reduce the risk of phototoxicity associated with endoillumination in vitreoretinal surgery, allowing higher exposure times than with optic light fibers alone. Spectral filters may affect intraoperative luminance, but do not alter color contrast. Amber filters showed superiority over green and yellow filters. CONCLUSION: The choice of light sources coupled to spectral filters is strongly suggested, especially in dye-assisted chromovitrectomy. Histological donor eye studies and large multicenter trials are needed to validate the amount of photoprotection provided by spectral filters before a general recommendation can be made.

Advancements of vitreoretinal surgical machines.

PURPOSE OF REVIEW: This article reviews current advancements in vitreoretinal surgical machines. RECENT FINDINGS: The most recent advancement in vitreoretinal surgical machines include 27-gauge vitrectomy probes, new cutter designs, higher cut rate, improved intraocular pressure control, new endoillumination technologies, and combined anterior/posterior segment capabilities. SUMMARY: With recent advancements in vitreoretinal surgical machines, surgical incisions have become less traumatic and fluidics control has led to a more controlled posterior segment vitrectomy.

Clinical utility of intraoperative optical coherence tomography.

PURPOSE OF REVIEW: To explore the clinical utility of intraoperative optical coherence tomography (iOCT) for the management of vitreoretinal conditions. RECENT FINDINGS: The role of iOCT in guiding surgical decision-making and surgical manipulations during vitreoretinal procedures has been evaluated by multiple studies. This imaging modality is emerging as a valuable asset during procedures for vitreoretinal interface disorders, retinal detachments, submacular surgeries and therapeutics, and in pediatric conditions such as retinopathy of prematurity. iOCT allows the surgeon to assess completion of surgical goals and to directly monitor the architectural impact of instrument-tissue interactions that may correlate with eventual prognosis. The technology has gone through numerous iterations with the eventual goal being the development of a user-friendly, efficient, and integrated system that provides surgeons with 'real-time' feedback during ophthalmic surgeries to allow for a comprehensive image-assisted vitreoretinal surgery platform. SUMMARY: The role of iOCT in ophthalmic surgery has been evolving with the help of ongoing research to define its utility in the operating room and to develop integrative technologies. Advancements in OCT-friendly surgical instrumentation and in integrative capabilities of this technology may help achieve more widespread adoption of this technology in the vitreoretinal surgical theater. Although the evidence appears clear that this technology impacts surgical decision-making, additional research is needed. However, further research is needed to determine the influence of this technology on overall patient outcomes.

Mobility-Enhancing Coatings for Vitreoretinal Surgical Devices: Hydrophilic and Enzymatic Coatings Investigated by Microrheology.

Ophthalmic wireless microrobots are proposed for minimally invasive vitreoretinal surgery. Devices in the vitreous experience nonlinear mobility as a result of the complex mechanical properties of the vitreous and its interaction with the devices. A microdevice that will minimize its interaction with the macromolecules of the vitreous (i.e., mainly hyaluronan (HA) and collagen) can be utilized for ophthalmic surgeries. Although a few studies on the interactions between the vitreous and microdevices exist, there is no literature on the influence of coatings on these interactions. This paper presents how coatings on devices affect mobility in the vitreous. Surgical catheters in the vasculature use hydrophilic polymer coatings that reduce biomolecular absorption and enhance mobility. In this work such polymers, polyvinylpyrrolidone (PVP), polyethylene glycol (PEG), and HA coatings were utilized, and their effects on mobility in the vitreous were characterized. Hydrophilic titanium dioxide (TiO2) coating was also developed and characterized. Collagenase and hyaluronidase enzymes were coated on probes' surfaces with a view to enhancing their mobility by enzymatic digestion of the collagen and HA of the vitreous, respectively. To model the human vitreous, ex vivo porcine vitreous and collagen were used. For studying the effects of hyaluronidase, the vitreous and HA were used. The hydrophilic and enzymatic coatings were characterized by oscillatory magnetic microrheology. The statistical significance of the mean relative displacements (i.e., mobility) of the coated probes with respect to control probes was assessed. All studied hydrophilic coatings improve mobility, except for HA which decreases mobility potentially due to bonding with vitreal macromolecules. TiO2 coating improves mobility in collagen by 28.3% and in the vitreous by 15.4%. PEG and PVP coatings improve mobility in collagen by 19.4 and by 39.6%, respectively, but their improvement in the vitreous is insignificant at a 95% confidence level (CL). HA coating affects mobility by reducing it in collagen by 35.6% (statistically significant) and in the vitreous by 16.8% (insignificant change at 95% CL). The coatings cause similar effects in collagen and in the vitreous. However, the effects are lower in the vitreous, which can be due to a lower concentration of collagen in the vitreous than in the prepared collagen samples. The coatings based on enzymatic activity increase mobility (i.e., >40% after 15 min experiments in the vitreous models) more than the hydrophilic coatings based on physicochemical interactions. However, the enzymes have time-dependent effects, and they dissolve from the probe surface with time. The presented results are useful for researchers and companies developing ophthalmic devices. They also pave the way to understanding how to adjust mobility of a microdevice in a complex fluid by choice of an appropriate coating.