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To the Editor:
We read with great interest the article “Heads-up surgery for vitreoretinal procedures: An Experimental and Clinical Study.” In this study Eckardt et al1 aim to investigate the feasibility of performing vitrectomies using a three-dimensional imaging system (3D). In the paper they first nicely compared the ability to perform meticulous tasks using the 3D system versus the conventional microscope. Then they reported on their first 8 months experience of 3D system routinely use. In the discussion section the authors highlight the advantages of the new 3D system, and they conclude that it is suitable for routinely use. In particular, they focus on the importance of ergonomic benefit for the surgeon provided by the “heads-up” position, as underlined in the title. We also recently tested the 3D system in our surgical routine. Although we do agree with most advantages described by Eckardt et al, we have some concerns about the real ergonomical improvement for the surgeon. In fact, even though the head is no more fixed to the microscope, the operator body (from the shoulders down to the back and the legs) is still blocked in the same sitting position that may cause upper and lower back troubles. Moreover, the neck remains fixed in a rigid position as the surgeon is highly focused looking at the screen for most of the procedure timespan. For sure we are waiting for new microscopes, designed exclusively for 3D use that will improve head and neck ergonomic. Instead, we believe the key advantages of this new system are the digital image processing possibilities. In addition to the possibilities to reduce the light source by increasing the gain and to “adjust” the brightness that the authors discuss in the paper, we think it is worth to mention also the possibility to use filters to obtain a better visualization of certain structures such as the vitreous, the blood, or a fibrotic membrane. A further advantage is the tutorial capabilities of the system. The senior surgeon can see exactly the same image of the fellow, thus being more easily able to guide him through a difficult part of the procedure.
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