Three-dimensional (3D) imaging represents one of the most revolutionary advancements in retinal surgery in recent years. Traditional retinal surgery has relied primarily on two-dimensional imaging, which limits surgeons' ability to appreciate the depth and intricate structures of the retina.
Novel 3D technology has revolutionized surgical approaches by providing a more detailed and immersive view of the retina, enabling surgeons to operate with increased precision and accuracy.
Heads-up display systems vs. traditional microscopy
In heads-up imaging, rather than looking directly through a microscope, a stereoscopic image is projected onto a high-resolution display screen from a 3D camera.
These systems utilize two optical channels that create slightly different images, which are then combined to generate a comprehensive 3D visualization of the surgical field. This approach fundamentally changes how surgeons interact with the delicate tissues of the eye during procedures.
Clinical advantages of 3D heads-up imaging
By projecting stereoscopic images onto high-resolution digital monitors, 3D heads-up display (HUD) systems allow surgeons to operate in a natural, upright position while benefiting from enhanced depth perception, reduced illumination requirements, and digitally augmented visualization.
3D heads-up imaging offers:
- Improved illumination and reduced phototoxicity
- Enhanced depth of field
Improved illumination and reduced phototoxicity
A significant advantage of 3D heads-up imaging is its ability to provide enhanced visualization while requiring less illumination intensity. Multiple independent studies have consistently demonstrated this benefit across different procedures and settings.1,2,3,4
Through electronic amplification of the camera's signal, surgeons can obtain brighter and more detailed images of the surgical field while substantially reducing the illumination intensity from the microscope light source and endoillumination probe.
This reduction in illumination is particularly important given the potential risk of retinal phototoxicity during prolonged procedures. By achieving better visualization with less light, 3D HUD systems may offer a significant safety advantage, especially for complex cases that require extended surgical times.
Enhanced depth of field
Depth of field refers to the range of axial depth that appears in focus simultaneously. It essentially refers to how much of the surgical field appears in focus simultaneously.
With a larger depth of field, surgeons can maintain focus on several critical eye structures throughout the surgery. While conventional microscopes rely on the surgeon’s ability to accommodate, 3D HUD imaging produces a larger depth of field that is not impacted by the user’s visual function.
One study found that the depth of the field in 3D systems is up to 3x larger than the standard microscope.5 A survey comparing the depth of field, lateral resolution, and image quality of 3D HUD and traditional microscopy found that surgeons preferred the 3D system, especially at increased magnifications.6
Figure 1: Summary of currently available 3D HUD systems for retinal surgery. Click here for more information on each of these devices.
Procedure-specific applications for 3D HUD
The clinical adoption of 3D HUD technology across various retinal procedures has been supported by a growing body of evidence. The largest assessment to date analyzed 5,483 eye surgeries performed over a 3-year period.7
This study evaluated the technology across the spectrum of ophthalmic procedures, including cataract, cornea, oculoplastics, glaucoma, strabismus, and retinal surgeries. For retinal applications specifically, the study examined episcleral surgery for retinal detachments, vitrectomies for various indications, macular surgery, and trauma surgery.7
The results were compelling—3D HUD emerged as the preferred viewing system for all vitreo-retinal procedures, with retina surgery receiving the highest satisfaction scores among all subspecialties. Importantly, this preference did not come at the expense of safety or efficacy, as no significant differences in procedural complications were identified between the two viewing systems.7
Retinal detachment repair
The management of retinal detachment represents one of the most challenging procedures in retinal surgery, demanding precise visualization and tissue manipulation. The application of 3D HUD technology to this critical area has been examined through multiple clinical studies with consistently reassuring results.
In 2017, a study investigated the NGENUITY 3D System for vitrectomy in the repair of rhegmatogenous retinal detachment (RRD).4 Their findings revealed comparable procedural success rates between 3D HUD and traditional microscopy.
Notably, they observed that surgeons using the 3D system were able to avoid triamcinolone vitreous staining, suggesting that the enhanced visualization provided by digital filtering and higher resolution improved identification of vitreous remnants.
Further studies comparing 3D HUDs to traditional 2D imaging
Building on these initial observations, a study conducted in 2020 examined 23-gauge RRD surgery outcomes.8 Their results reinforced the equivalence of 3D HUD to traditional approaches regarding primary retinal reattachment rates, proliferative vitreoretinopathy development, and final best-corrected visual acuity.
While they observed initially longer surgical durations with the 3D system, this difference disappeared after surgeons completed approximately 35 cases, highlighting a learning curve that resolves with experience. A 2021 study focused on particularly challenging cases—primary and recurrent RRD complicated by proliferative vitreoretinopathy.3
Even in these complex scenarios, 3D HUD demonstrated comparable surgical duration and equivalent anatomical and functional outcomes to traditional microsurgery. Notably, the 3D HUD group required significantly lower endo-illumination, and surgeon satisfaction was significantly higher, suggesting both safety and experiential benefits.
Two additional studies further reinforced these conclusions, demonstrating consistent equivalence in anatomical success, functional outcomes, complication rates, and surgical duration across different patient populations and settings.9,10 This consistency across multiple independent studies strongly suggests that 3D HUD technology provides a viable alternative to traditional microscopy without compromising patient safety or surgical efficacy.
Beyond pars plana vitrectomy (PPV), the application of 3D HUD technology to scleral buckling procedures has also shown promising results. A 2022 investigation found that 3D visualization with a guarded light pipe yielded comparable anatomical and visual outcomes to traditional methods, while improving ergonomics, enhancing educational value, and reducing operative times.11
How 3D HUD technology can change retinal detachment repair
An innovative application of 3D HUD technology was explored in 2023 when a study investigated whether the enhanced visualization afforded by 3D HUD technology might allow surgeons to exclude perfluorocarbon liquid (PFCL) during retinal detachment repair. PFCL retention is a recognized complication that can cause permanent visual impairment through damage to retinal pigmented epithelium and photoreceptors.12
This comparative study found no statistically significant differences in retinal reattachment rates or subretinal fluid residual between PFCL-included and PFCL-excluded groups. Remarkably, the PFCL-excluded approach demonstrated significantly shorter operation times and a trend toward greater BCVA improvement.12
When performing PPV surgery for RRD without PFCL, it can be challenging to visualize the surgical field under a microscope with air-filled eyes. With the use of 3D HUD imaging, this challenge can be lessened through a wider field of view, improved illumination, and improved image resolution.
3D HUD technology provides sufficient visualization of an air-filled eye, meaning the use of PFCL and its associated adverse effects can be avoided.
Epiretinal membrane surgery
The management of epiretinal membranes requires delicate manipulation of tissue planes at the macular surface. A 2023 study demonstrated that 3D HUD technology delivers improvements in BCVA and central macular thickness equivalent to those achieved with traditional microscopy.13
More remarkably, 3D HUD was associated with significantly lower rates of epiretinal membrane recurrence and dissociated optic nerve fiber layer occurrence, suggesting potential advantages for long-term outcomes.13
While surgical times were generally comparable between approaches, one study did identify longer macular peel times with 3D HUD, potentially reflecting the learning curve associated with adapting to a new visualization system for this particularly delicate maneuver.14
Macular hole surgery
Macular hole repair demands precise manipulation at the fovea—the center of highest visual acuity. Multiple independent studies have consistently demonstrated that 3D heads-up imaging yields comparable results to traditional microsurgery in terms of procedure duration, visual prognosis, and postoperative complications.15,16,17
Interestingly, one of these studies observed a significant improvement in macular hole closure rates with 3D heads-up imaging, suggesting a potential advantage that warrants further investigation.16 The consistent finding of at least equivalence across multiple studies provides strong reassurance that 3D HUD technology can be safely adopted for this procedure without compromising patient outcomes.
The advantages of 3D visualization systems are most pronounced in complex vitreoretinal cases where surgical precision is directly linked to functional outcomes. For instance, in macular hole surgery, the success of the procedure often hinges on the surgeon's ability to perform delicate maneuvers such as internal limiting membrane (ILM) peeling or abrasion.18
The enhanced depth perception and magnification offered by heads-up displays are critical for these intricate steps, which have been shown to be effective in promoting macular hole closure. Similarly, in cases of retinal detachment complicated by proliferative vitreoretinopathy (PVR), accurately identifying and dissecting fine membranes from the retinal surface is paramount.19
The improved visualization and digital filtering capabilities of 3D systems can aid surgeons in managing PVR, a condition that remains a significant predictor of surgical failure in retinal detachment repair. By providing a more detailed and immersive view, these technologies empower surgeons to better address the most challenging aspects of retinal surgery, potentially leading to improved patient outcomes.
Diabetic retinopathy management
The management of diabetic retinopathy presents unique challenges, particularly in evaluating retinal blood flow during surgery. A 2023 case series demonstrated how the NGENUITY 3D HUD system effectively addresses this limitation by enabling intraoperative 3D fluorescein angiography during pars plana vitrectomy.18,20
In patients with vitreous hemorrhage secondary to proliferative diabetic retinopathy, the system successfully displayed abnormal fluorescein angiography findings, while simultaneously allowing surgeons to perform complex maneuvers such as segmentation and delamination of fibrovascular proliferative membrane and targeted panretinal photocoagulation.19,21
Similar results were achieved in patients with branched retinal vein occlusion complicated by vitreous hemorrhage and neovascularization, suggesting broader applicability across vascular retinal disorders.
Focus on novel techniques with 3D HUD technology
The enhanced visualization provided by 3D HUD technology has also enabled the development of novel surgical techniques. One innovative application was explored in a small case series investigating scleral indentation and transillumination for single-surgeon, unassisted vitrectomy and vitreous base shaving.20,22
Traditionally, these procedures require a skilled assistant to provide adequate visualization of the peripheral retina. However, the digital enhancement capabilities of 3D HUD systems allowed surgeons to achieve a well-lit view of the surgical field while operating independently.
In five of six cases evaluated, three different surgeons determined that the visualization provided through scleral transillumination with 3D HUD was adequate to safely complete the procedure without assistance.20,22 This finding suggests that 3D visualization technology may not only enhance existing surgical approaches but also enable entirely new techniques that could improve efficiency in the operating room.
The benefits for surgeons of 3D heads-up imaging
The two primary benefits of 3D heads-up imaging for surgeons are improved ergonomics and enhanced collaboration capabilities.
Ergonomic advantages
One of the most compelling advantages of 3D heads-up imaging over traditional microsurgery is the significant improvement in ergonomics. The conventional posture required for microscope use—hunched over with neck flexed for extended periods—has been associated with musculoskeletal strain and fatigue.
In contrast, 3D imaging allows surgeons to sit upright in a more natural posture while viewing a large 3D monitor, substantially reducing neck, shoulder, and back pain commonly reported during lengthy procedures. Beyond physical comfort, the visual experience itself is transformed.
Traditional microscope use demands prolonged binocular vision, often leading to significant eye strain and fatigue. The 3D imaging approach reduces these visual demands while maintaining or even enhancing depth perception.
A 2016 study compared the heads-up method with traditional microsurgery through a series of precision tasks.1 In total, 91.7% of participating surgeons preferred the ergonomics of the heads-up method, and the approach yielded significantly fewer procedural errors, suggesting potential benefits for surgical outcomes.
Educational and collaborative capabilities
3D HUD technology also has significant educational implications. Traditional microsurgical techniques create an inherently isolated visual experience, as only the surgeon operating the microscope achieves true stereopsis and adequate visualization of the surgical field. Three-dimensional viewing systems fundamentally change this dynamic by enabling everyone in the operating room to observe identical stereoscopic images.
A 2020 survey comprehensively assessed this educational impact across all operating room personnel, revealing benefits that extended beyond surgical trainees.21,23 Medical students reported significantly improved identification of surgical landmarks and overwhelmingly preferred 3D imaging as a learning tool compared to a microscope or 2D display options.
Residents reported an enhanced understanding of retinal anatomy, greater comfort in asking questions during procedures, and improved ergonomics during observation. The advantages extended to the entire surgical team as well. Nursing staff reported an improved ability to track case progress and anticipate needed instruments.21,23
Attending surgeons noted greater awareness of trainees and increased comfort with resident and fellow autonomy. Interestingly, anesthesiologists were the only personnel who reported similar or worse engagement, citing difficulty switching between the 3D screen and anesthesia equipment.21,23
These findings were further reinforced by a 2021 survey, which found that surgeons reported an overall improved experience with 3D technology, while trainees noted significant improvements in illumination, maneuverability, reduced glare, decreased eye and musculoskeletal strain, enhanced communication, and better knowledge sharing.22,24 These educational benefits may accelerate training and improve the collaborative aspects of surgical care.
A spotlight on current 3D HUD systems
The evolution of 3D technology has been marked by several innovative systems designed to enhance surgical visualization and accuracy.
TrueVision pioneered the field by developing a digital camera that attaches to operating microscopes and displays images on a screen. Although this system is no longer available for use, it helped demonstrate the feasibility of the technology.
NGENUITY 3D Visualization System
The NGENUITY 3D visualization system emerged as a collaboration between TrueVision and Alcon in 2016.
This system delivers stereoscopic viewing through:
- Passive 3D polarized glasses for the surgeon and observers
- 55-inch 4K OLED high-definition display
- Superior display quality with enhanced contrast, brightness, and color range compared to LCD displays
- Quantifiable improvements over traditional analog microscopes25
- Up to 48% increased magnification
- 42% greater depth resolution
- 5x extended depth of field
Distinctive technological features include:
- Specialized digital imaging modes
- Tissue Detail Mode for enhanced visualization during vitreous and membrane removal
- Performance Green Mode for optimized contrast with green dyes during macular work
- Blue Boost Mode for enhanced visualization of blue dyes during ERM and ILM peeling
- DATAFUSION augmented reality
- Overlays real-time surgical data onto the visual field
- Provides immediate access to vitrectomy parameters, intraocular pressure, flow rates, and system performance metrics
- Illumination optimization
- Enables a substantial reduction in light intensity26
- Up to 40% less microscope light
- 60% less chandelier light
- 20% less endo-illuminator intensity
- Supports chromovitrectomy with lower dye concentrations and may eliminate the need for dye at all27,28
- Enables a substantial reduction in light intensity26
Beyond the technical advantages, the HUD design significantly improves ergonomics by reducing neck strain during lengthy procedures.29,30 The system also serves as an excellent teaching tool, allowing for the entire operating room to simultaneously view the same high-resolution images as the surgeon.28 Additionally, it offers both 3D and 2D recording capabilities for surgical review, presentations, and training purposes.
Artevo 850
The Artevo 850 3D HUD system delivers real-time, high-resolution stereoscopic images of the operating field on a display screen.
Key specifications include:
- 55-inch 4K stereoscopic monitor
- Exceptional clarity and natural color reproduction for visualization of fine structures
- Improved depth of field that reduces the need for frequent refocusing and improves workflow efficiency
Distinctive technological features include:
- Augmented reality integration
- ZEISS AdVision technology enables real-time data overlays without obstructing the surgical view
- Integrated intraoperative OCT (iOCT)
- Provides 39% more image information than previous versions31
- Enhances real-time visualization of epiretinal membranes, macular edema, posterior hyaloid traction, and retinal detachment
- Adaptive technology
- The AutoAdjust feature automatically optimizes settings when switching between anterior and posterior segments
- The hybrid mode allows seamless switching between digital and optical imaging
- RESIGHT 700 non-contact retina visualization system provides detailed imaging even at reduced light intensities
- Light reduction capabilities
- Reduces light intensity by up to 85% while maintaining optimal brightness
- More than 75% of retina surgeons report significant reductions in light intensity during procedures31
Beyond its clinical advantages, the system offers cloud integration for easy access to surgical data across multiple locations. It also serves as an ideal teaching tool, allowing trainees to view exactly what the surgeon sees.
Beyeonics One
The Beyeonics One offers a distinctly different approach to 3D visualization, utilizing an immersive augmented reality (AR)-based surgical headset rather than a traditional monitor system.
The system includes:
- 270-degree rotatable camera head with >8K resolution, low-noise cameras
- LED-based illumination optimized for tissue clarity
- 24-inch rotating touchscreen interface for OR team view
- Smaller physical footprint compared to other 3D HUD systems
- Zero perceived image latency for maintained hand-eye coordination
- Capacity for on-site and periodic software updates
Distinctive technological features:
- Immersive AR headset interface
- Surgeons control focus, zoom, pan, and illumination through intuitive head gestures
- Eliminates the need for manual adjustments during surgery
- Future capabilities will include embedded applications such as iOCT integration
- Invisible light technology
- Utilizes infrared illumination rather than high-intensity visible light
- Improves visualization through dense cataracts, hemorrhages, and cloudy corneas
- Further reduces the potential for retinal phototoxicity
- Dual headset capability
- Two surgical headsets can be connected simultaneously
- Allows for shared 3D/2D visualization between the surgeon and the assistant/trainee
- Workflow optimization
- Rotatable camera head allows a fixed OR setup
- Zero additional turnover time between right and left eye surgeries
- Digital filters enhance tissue and membrane contrast during different surgical phases
SeeLuma
The SeeLuma is another 3D system available to vitreoretinal surgeons.
The system features digital binoculars with the following pros:
- Freely positioned for optimal surgeon comfort
- Dual display options with either 55” or 31” 3D 4K monitors
- C-shaped suspension arm design that optimizes positioning flexibility
- Motorized optical 6x zoom capability
- XYZ coupling mechanism for intuitive focusing
- Built-in keratoscope for intraoperative assessment
Distinctive technological features include:
- Cinematographic-grade visualization
- Superior color reproduction and contrast compared to traditional systems
- 9x depth of field enhanced for improved visualization across various focal planes
- Lower illumination requirements than conventional optical systems
- Multiple digital and physical retina protection filters to ensure patient safety
- Integrated workflow optimization
- OCULUS BIOM 5c integration with automatic adjustments for
- Zoom parameters
- Focus speed
- White balance calibration
- Customizable footswitch layout
- Built-in 4K 3D recording capabilities with in-system editing functionality
- OCULUS BIOM 5c integration with automatic adjustments for
- Interactive surgical assistance
- A touchscreen interface allows real-time annotations and surgical notes
- Draw directly on the live surgical image to highlight structures or guide assistants
- Multiple wireless displays support simultaneous 2D and 3D viewing (up to 4K resolution)
Conclusion
As mounting clinical evidence affirms the safety, efficacy, and ergonomic advantages of 3D HUD systems, their adoption in retinal surgery continues to expand.
With ongoing advancements, including the integration of artificial intelligence, augmented reality overlays, and immersive visualization platforms, the future of retina surgery lies at the intersection of digital precision and surgeon-centered design.
These innovations not only promise to elevate the surgical experience but also enhance clinical outcomes, particularly in complex retinal procedures where precision and clarity are paramount.
