With ongoing advancements in vitreoretinal surgery, breakthrough technologies are changing the landscape
Over the years, vitreoretinal surgery has undergone a dramatic transformation—thanks to cutting-edge technologies that redefine precision and effectiveness. Innovations like 3D viewing systems deliver exceptional visualization, while robotic tools offer precise control, setting new benchmarks in surgical practice.
Digital technologies are revolutionizing the conventional operating room, allowing vitreoretinal surgeons better visualization, greater precision and efficiency. Below, we explore the latest cutting-edge technologies reshaping retinal surgery today.
3D viewing systems at a glance
Enhanced Visualization: 3D viewing systems provide high-definition imaging that offers better depth perception. This improves the surgeon’s ability to navigate and manipulate delicate retinal tissues.
Wide-Angle Systems: Advanced wide-angle viewing systems offer a broader field of view and improved visualization of the retina, which is vital in complex surgeries.
Prof. Dr. Mae-Lynn Catherine Bastion, a vitreoretinal surgeon at the National University of Malaysia (UKM) and UKM Specialist Centre, said the 3D heads-up system offers various advantages. It is particularly beneficial for vitreoretinal surgery due to its magnification and color-adjustability.
“3D viewing has many advantages. Surgeons benefit from a more relaxed posture, reduced neck pain, and less presbyopia. On the other hand, patients experience reduced glare, while students learn from large, clear images that provide better depth perception,” shared Prof. Bastion.
These systems are more comfortable for surgeon ergonomics and are particularly beneficial for presbyopic surgeons—especially during lengthy and complex posterior segment surgeries. Surgeon ergonomics can affect surgical performance, and the 3D heads-up display eliminates the need to look through a microscope—which can cause back and neck pain.
It also works well as an effective teaching tool, allowing everyone in the room to observe the surgery in crisp, clear 3D detail simultaneously. In contrast, traditional operating microscopes require the surgeon to perform surgery while looking through the binoculars, while students view 2D images on a monitor.
“We have had two demos placed at our center in the last five years— the NGENUITY (Alcon; Geneva, Switzerland) and the Artevo 800 (Carl Zeiss Meditec; Jena, Germany),” said Prof. Bastion.
“We have published our experience on the NGENUITY.* This study evaluated the perspectives of surgeons and postgraduate trainees of the first 3D heads-up ophthalmic surgery demonstration conducted at our hospital during various eye surgeries with this viewing system,” she shared.
The paper reported that surgeons and trainees were more satisfied with the 3D systems overall, noting various subcomponents of visualization, ease of use and education.
“We have an ongoing study on the Artevo 800. In February 2024. I performed the first macula hole repair in Malaysia using the Artevo 800 at the Hospital Canselor Tuanku Muhriz, UKM,” she continued.
She explained that while she has used the 3D systems for cataract and macular surgery, the advantages are more pronounced in posterior segment surgeries.
“Outcomes were good with no complications,” noted Prof. Bastion. “The technology is expensive, so we have not been able to have the systems on a permanent basis. Despite the high cost, however, the future is bright—particularly if such surgical teaching tools can be made available for our promising eye surgeons.”
Robotics: A quick overview
Robotic Assistance: Robotic systems provide surgeons with precise instrument control and stability. These systems can assist in performing delicate maneuvers with greater accuracy and reduce hand tremors.
Automated Tools: Some robotic systems offer automated tools for tasks like laser delivery or retinal laser photocoagulation, which can enhance precision and consistency.
Standard retinal surgeries currently involve manual techniques and instrumentation. However, human motor control has its limits, and surgeons experience unavoidable physical tremors. Robotic assistance can help overcome these by guiding surgical movements.
Some examples include the Johns Hopkins Steady-Hand Eye Robot and the Preceyes Surgical System (Preceyes BV, a ZEISS company). Designed for retinal microsurgery, the Johns Hopkins Steady-Hand Eye Robot allows the surgeon to fully control the robot while producing more precise and tremor-free moves. Meanwhile, the Preceyes Surgical System aims to provide surgeons
with better precision for positioning and holding instruments. It is compatible with a wide range of 23G, 25G, and 27G instruments and can be used for patients under local or general anesthesia.
Due to their substantial costs, robotics are not expected to see widespread use just yet, said Prof. Bastion. However, there is potential for their application in macula surgery to reduce the effects of hand tremors in surgeons, she noted.
A snapshot of intraoperative OCT
Imaging Technique: Intraoperative optical coherence tomography (iOCT) uses light waves to capture detailed images of the tissue being operated on, providing high-resolution images of tissue structures during surgery.
Real-Time Visualization: By providing immediate feedback, iOCT helps surgeons make more informed decisions during the procedure. This can be crucial for assessing damage, ensuring proper placement of implants, and verifying the success of repairs.
High Resolution: iOCT produces high-resolution images, which allows for the detailed examination of microstructures within the tissue. This level of precision is particularly important in delicate surgeries, such as those involving the retina.
iOCT is particularly beneficial for vitreoretinal interface conditions, including macular hole surgery and membrane peeling, as well as for retinal detachment repair and other vitreoretinal procedures.
According to Prof. Bastion, in cases of myopic macular holes, improved real-time visualization ensures accurate localization—as these can be small and difficult to visualize, especially with chorioretinal atrophy. This can help reduce surgical error, she added.
She also noted that for diabetic tractional retinal detachment (TRD) with membranes, better visualization enables a more complete removal of membranes. iOCT is also useful in epiretinal membrane (ERM) removal to ensure that no macular hole has been caused and that the membrane removal is complete.
The future is within reach
Although these new technologies provide many benefits, their cost remains a significant barrier that could limit accessibility. Nevertheless, utilizing 3D headsup display technology, roboticassisted surgery, and iOCT may help improve surgical precision, reduce complications, and ultimately enhance patient outcomes in vitreoretinal surgery.
With ongoing research and hopefully improved access to these digital advancements, the future looks bright for retinal surgery.
Editor’s Note: A version of this article was first published in PIE Magazine Issue 31.
Reference
- Cheng TC, Yahya MFN, Mohd Naffi AA, et al. Evaluation of Three-Dimensional Heads up Ophthalmic Surgery Demonstration From the perspective of Surgeons and Postgraduate Trainees. J Craniofac Surg. 2021;32(7):2285-2291.
