Disclosures: Garg reports he is a consultant for Ocutrx. Lanzetta reports no relevant financial disclosures.
April 15, 2021
3 min read

Does augmented reality have a potential role in ophthalmic surgery?

Disclosures: Garg reports he is a consultant for Ocutrx. Lanzetta reports no relevant financial disclosures.
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Advances are phenomenal

Augmented reality (AR) has gradually become a substantial part of modern life, and I believe it will certainly be part of how we approach our surgical patients in the future.

There are several companies working at new “smart” technologies for visualization during surgery as well as diagnostic devices that will help doctors to deliver care more precisely, safely and efficiently. Some are at an advanced prototype stage and hopefully might be launched within the next year or so. Technologies such as head-mounted displays provide not only a high-resolution 3D visualization of the operating field, but also make all relevant data accessible and may integrate artificial intelligence (AI) algorithms, which should help surgeons.

Sumit “Sam” Garg, MD
Sumit “Sam” Garg

Diagnostics-wise, there is one thing we look forward to, and this is a better prediction of effective lens position. AR and AI will provide better modeling for accurate prediction of postoperative anterior chamber depth, improving the refraction prediction performance of a given lens. MIGS is another area in which AR can enhance our localization and quantification of blood flow and aqueous flow, helping to target the specific area of the trabecular meshwork where we want to direct our treatment.

We are going to witness major progresses in this field, from pure visualization to using live data from the patient to enhance their care. I have seen both the Beyeonics and the Ocutrx prototypes and think the advances these types of devices offer are quite phenomenal. Both incorporate heads-up displays that offer surgeons a more comfortable, ergonomic way of performing surgery, minimizing fatigue and neck and back strain. Head movements are free, and all the information is accessible without looking away from the surgical field. Is it worth the cost and effort to implement? Personally, I think it definitely is. In general, I am favorable to new technologies, although they are more often than not more expensive than the standard of care until they become mainstream.

Sumit “Sam” Garg, MD, is an OSN Cataract Surgery Board Member and associate professor of ophthalmology, vice chair of clinical ophthalmology and medical director at Gavin Herbert Eye Institute, University of California, Irvine.


Great potential, but further improvement needed

Augmented reality jumped into our theatres after the introduction of 3D digital systems.

Paolo Lanzetta, MD
Paolo Lanzetta

Ngenuity 3D by Alcon was the first “heads-up” digital solution on the market, followed by Artevo 800 by Zeiss, which allows the use of both the optical microscope and 3D digital visualization. A further step was made with “head-mounted” technologies. These include the Sony HMS-3000 MT device and the more recent and under development Beyeonics One and Ocutrx OR-Bot.

Although it is clear that augmented reality has and will have a role in ophthalmic surgery, these technologies are still evolving, and further improvement is needed.

One relevant limitation may be linked to the resolution of digital displays as compared with the human eye. Although we do not see in pixels, we may assume that human eyes have 576 megapixels or 576 million individual pixels. Now, 8K displays have only 33,177,600 pixels. So, theoretically, the image quality or resolution of humans is still superior to digital technologies. On the other hand, the human eye cannot enhance images whereas digital technology can easily do it.

Other issues may be related to the routine and long-term use of these devices. Heads-up systems do not prevent back and neck pain because the monitor is not perfectly aligned with the surgeon’s position. Head-mounted systems may be more comfortable although the burden of their weight should be carefully considered. Lag and latency in digital images are now solved problems.

So, what are the true potential advantages of digital imaging during ophthalmic surgery? Once again, we should refer to the concept of augmented reality through which the surgeon has access in real time to a digitally amplified camera signal. This translates, for example, in image amplification during very low illumination levels to reduce light toxicity, 3D epiretinal membrane enhancement and other unlimited possibilities. Intraoperative data overlay and fusion are other interesting features that allow the surgeon to accurately align preoperative OCT, fluorescein angiography and other imaging modalities. Today, 4D OCT technology can be integrated into the operating microscope and constitutes an augmented reality system itself. Specific alignment software may help anterior segment surgeons during incisions, circular capsulorrhexis, toric IOL positioning and other maneuvers, improving accuracy and reducing errors.

Augmented reality does not only have potential, but it will become a pivotal component of our surgery.

Paolo Lanzetta, MD, is a professor of ophthalmology, University of Udine, and founder and scientific director of IEMO – European Institute of Ocular Microsurgery, Udine, Italy.