The digital OR: Retina care of tomorrow

Retina surgeons have no shortage of cases—the packed schedules and last-minute add-ons we see on our calendars testify to this fact. Because we are so busy ensuring that our cases are performed safely and effectively, we sometimes overlook how the surgical suite changes around us. Let us use this time to pause and consider how evolutions in digital technology are changing our operating rooms (ORs) and to look ahead at how forthcoming innovations could affect the way we operate.

Heads-up 3D displays

Heads-up 3D displays in the surgical suite represent a significant advancement in surgical technology over the past decade. Many modern ORs have adopted these advanced visualisation platforms to enhance surgical precision and comfort.

I have used heads-up 3D displays in the OR for 8 years and realised several of the benefits outlined by my colleagues in the literature and on the podium. The ergonomic benefits of sitting upright quickly become apparent. The ability to easily apply filters and enhance contrast, allowing improved visualisation of tissue planes and through media opacities (e.g., haemorrhages that block a full posterior view), means a more precise surgical technique. Surgeons in teaching settings may find they can better instruct residents and fellows as they share an identical view.

For similar reasons, surgical assistants may be better able to anticipate surgical steps and increase procedural efficiency. These benefits quickly become self-evident when a surgeon adopts heads-up 3D displays.

We have even seen incremental innovations to heads-up technology since its introduction. This suggests that the innovators are only beginning to improve our ORs. Ergonomic improvements have taken hold: for example, an articulating C-arm allows users to look directly in front of them, eliminating the need to turn their heads to look past the scope’s column.

Also, surgeons now have the option to use digital binoculars on some platforms in addition to (or instead of) a heads-up display screen, allowing greater optionality for visualisation based on surgeon preference. Adjustments such as these flatten the learning curve for trainees and attendings, easing the pathway to adoption.

The benefits of a heads-up 3D display are not merely anecdotal and matters of convenience. Data from studies have shown that heads-up 3D visualisation is associated with improved outcomes compared with standard-of-care approaches in some cases. Reddy et al compared macular hole surgery outcomes in cases performed by trainee surgeons who did or did not use heads-up 3D visualisation and found that the macular hole closure rate was significantly higher in the group that used heads-up 3D displays (86% vs 60%; P < .004).¹ Similarly, Kim et al reported that using heads-up 3D displays in cases of epiretinal membrane (ERM) surgery was associated with decreased rates of ERM recurrence and dissociated optic nerve fibre layer presence compared with conventional visualisation.²

Many of us in retina share this enthusiasm for the potential of heads-up 3D displays to reshape ophthalmology. Razavi et al recently published an editorial that explored the promise of this technology to expand access to care.³ They pointed to how heads-up displays could allow teleophthalmology to leverage remote assistance from specialists and could be used in a virtual reality landscape to expand access to training and education not limited by geographic constraints.

Intraoperative optical coherence tomography

The ability to quickly characterise pathologic conditions in the OR can make a difference in surgical decision-making and postoperative follow-up requirements.

Take, for instance, a case in which you peel a thick membrane only to uncover a macular hole with morphology that appears different after the peel. Is it a lamellar macular hole? Is it a full-thickness macular hole? With intraoperative optical coherence tomography (OCT), surgeons receive immediate imaging data that would otherwise be unavailable and can adjust their surgical approach in real time.

The effects of intraoperative OCT on surgery have been described extensively in the literature, particularly in the DISCOVER study (NCT02423213) led by Ehlers. Huang et al reviewed 41 patients from DISCOVER who underwent vitrectomy for conditions related to vitreomacular traction (VMT). The use of intraoperative OCT affected surgical decision-making in approximately 19% of patients.⁴

Yee et al reported on 84 eyes in DISCOVER that underwent macular hole repair.⁵ In 51% of cases, surgeons reported that intraoperative OCT provided useful information, such as confirmation of VMT release and the identification of occult residual membranes. In 12% of cases, intraoperative OCT specifically altered surgical decision-making.

Surgeons wishing to reduce the need for staining ERMs might consider embracing intraoperative OCT in their digital OR. Lorusso et al compared 2 cohorts that underwent ERM peeling, with the first group undergoing conventional peeling and the second undergoing peeling assisted by intraoperative OCT.⁶ They found that intraoperative OCT reduced the application of Brilliant Blue G, with 75% of cases in the conventional group requiring staining and 8% of the patients in the intraoperative OCT group requiring staining. Given these findings, surgeons seeking tools that can help them better perceive the surgical field and subsequently make more informed decisions may consider adding intraoperative OCT to their digital OR.

Robotics, software, artificial intelligence and the future of technology

We have heard plenty about software, robotics, and artificial intelligence (AI) in the consumer space. In the simplest sense, we envision manufacturers embracing robotics to complete rote tasks with greater precision, better safety, and reduced costs. The software we interact with has woven itself into the fabric of our lives to the point that we no longer consciously recognise its presence. And for all the speculation about how AI will affect our lives, we have reaped the benefits of AI-based systems for years, empowering educators, professionals, and domain experts to maximise their contributions.

But what impact, if any, might these innovations have on a modern OR? Given the careful and deliberate pace at which retina surgeons adopt new hardware, one might assume that innovations in these fields will make their way into the surgical suite in a decade or so, and even then, only in small steps. If retina surgeons do not adopt a new vitrectomy platform, how could they benefit from AI improvements—whatever they are—integrated into the latest hardware models?

However, upgrades to software can occur irrespective of whether new hardware is purchased. Incremental updates to surgical platforms will likely start introducing AI frameworks that already exist (eg, predictive models for macular hole closure) while returning high-quality data so that the algorithms driving such models can refine their precision. One can imagine a scenario in the
not-too-distant future where surgical preparation includes guidance from an AI model nourished by data from thousands of retina specialists.

We should expect innovation on the instrumentation front, too. For instance, forceps that correct for surgeon motion errors or hand tremors could leverage robotics engineering. Is there a possibility of robots executing fully automated vitrectomies in our lifetime? Perhaps, but my bet is that fully automated surgeries will go more the way of the flying car (a nice-to-have reserved for the realm of science fiction) than the way of the smartphone (a piece of technology foretold by science fiction and that proliferated in large part because of its affordability and breadth of capabilities).

What is next?

Retina specialists have a history of embracing surgical innovations, and even those of us who are firmly late adopters have been converted after seeing that patient outcomes have improved following the embrace of new technologies. Although it remains to be seen exactly how future standards of care will adopt innovations rooted in robotics, software and AI, we can safely say that a new, evolving standard of care that includes enhanced visualisation from a heads-up 3D display and intraoperative OCT imaging has raised the floor for the next generation of retina specialists.

Today, we look back on retinal surgeries of the 1970s with a mix of awe and disbelief. We cannot envision working that way. Perhaps in the 2070s, newly minted retina fellows will look at our current surgical standards the same way.

References

1. Reddy S, Mallikarjun K, Mohamed A, et al. Comparing clinical outcomes of macular hole surgeries performed by trainee surgeons using a 3D heads-up display viewing system versus a standard operating microscope. Int Ophthalmol. 2021;41(8):2649-2655. doi:10.1007/s10792-021-01792-3

2. Kim DJ, Kim DG, Park KH. Three-dimensional heads-up vitrectomy versus conventional microscopic vitrectomy for patients with epiretinal membrane. Retina. 2023;43(6):1010-1018. doi:10.1097/IAE.0000000000003762

3. Razavi P, Cakir B, Baldwin G, D’Amico DJ, Miller JB. Heads-up three-
dimensional viewing systems in vitreoretinal surgery: an updated perspective. Clin Ophthalmol. 2023;17:2539-2552. doi:10.2147/OPTH.S424229

4. Huang HJ, Sevgi DD, Srivastava SK, Reese J, Ehlers JP. Vitreomacular traction surgery from the DISCOVER study: intraoperative OCT utility, ellipsoid zone dynamics, and outcomes. Ophthalmic Surg Lasers Imaging Retina. 2021;52(10):544-550.
doi:10.3928/23258160-20210913-01

5. Yee P, Sevgi DD, Abraham J, et al. iOCT-assisted macular hole surgery: outcomes and utility from the DISCOVER study. Br J Ophthalmol. 2021;105(3):403-409. doi:10.1136/
bjophthalmol-2020-316045

6. Lorusso M, Micelli Ferrari L, Gisotti EN, et al. Success of iOCT in surgical management of ERM peeling. Eur J Ophthalmol. 2022;32(5):3116-3120.
doi:10.1177/11206721221085383

Mark Barakat, MD

Barakat is the founder and director of the Retina Macula Institute of Arizona in Scottsdale. He reports the following relevant disclosures: He is a consultant/speaker for Alcon and Bausch + Lomb.