Surgical Viewing; Do You See What I See?

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Since the introduction of digital three-dimensional viewing for vitreoretinal surgery by Eckardt, there has been increasing interest in the utility of three-dimensional viewing and any associated advantages or disadvantages compared with a conventional surgical microscope.1 The potential advantages include improved surgeon ergonomics, digital manipulation of the image by changing color profiles or camera gain, decreased endoillumination intensity, incorporation of preoperative and intraoperative digital images into the surgical viewing field, increased magnification with a larger field of view, enhanced depth of field (stereopsis), and improved surgical teaching.2,3 Potential disadvantages include the learning curve, latency between surgeon movement and visual perception, the vagaries of digital technology, and of course, cost.
Previous reports have described using high-resolution high dynamic range digital cameras and a high definition monitor positioned one to two meters from the surgeon instead of microscope oculars. Stereopsis is obtained using passive polarized glasses. As digital technology advances, we can expect continued improvement in resolution and can envision a day when a microscope becomes unnecessary.
In this issue of Retina, two groups report their preliminary experience using a commercially available head-mounted display system consisting of a digital organic light-emitting diode projection display for each eye mounted in a goggle device similar to that used for gaming or in military applications.4,5 This technology has been previously reported for nonophthalmic surgical indications such as laparoscopy.6
Both groups provide their subjective impressions concerning the quality of the surgical viewing experience, but are unable to provide any data to support their contention that this system is superior to a monitor-based three-dimensional viewing system or even a conventional surgical microscope. This is neither a surprise nor a criticism of the reports. After all, beauty is in the eye of the beholder. One can envision theoretical advantages or disadvantages for any viewing system. For example, the head-mounted system allows for only one other observer to share the surgeon's view while a monitor system allows all members of the surgical team to have the surgeon's perspective. Then again, the organic light-emitting diode projection to each eye may provide an enhanced viewing perspective for the surgeon. I suspect that some surgeons will embrace a head-mounted system while others will find a monitor system preferable and, of course, others still will prefer a surgical microscope. As surgeons, we have long known that there is no “best” way to do anything. We can be successful using a variety of techniques. Why should surgical viewing be any different? Now that we have options the question becomes which option works best for you? I plan to try them all.
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