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Photography in the field of ophthalmology has gone from conventional optical imaging on film to modern digital imaging. The availability of digital manipulation opens up vast opportunities for image enhancement, brightness adjustment, image sharing, graphics, and other functions commonly used in today’s practices.

Now, new developments in ophthalmic imaging and surgical microscopes are on the cusp of revolutionizing visualization of the surgical field. This article makes the case for the adoption of 3-D visualization technologies in retina surgery.

3-D DIGITAL IMAGING THROUGH THE YEARS

Live 3-D digital imaging has been used during corneal and cataract procedures since the introduction of the TrueVision 3D Surgical system (TrueVision Systems) in 2008.1 Its application in the retina world has only recently begun to take place, and it is slowly being adopted by retina surgeons.

Originally introduced in ophthalmology and neurosurgery as a rear projection system using dual stacked projectors and a retractable screen, the design progressed to a high-definition (HD) video monitor viewed with passive polarization 3-D glasses. Over time, the image quality, computational processing speed, and 3-D monitor resolution have improved significantly, leading to the current ultra-HD 4K 3-D monitor configuration now in use. This technology converts an optical microscope into a powerful digital imaging system. In 2014, the Leica M844 and Leica M822 ophthalmology microscopes (Leica Microsystems) were made globally available with TrueVision 3D visualization, recording, and editing technology. Combined with TrueVision’s fifth-generation ICM5 camera platform, the 4K display provides a new level of image quality and utility.

The improvement in image resolution and color quality has been a key factor in the adoption of 3-D digital imaging for heads-up live retina surgery.2 Additionally, 3-D camera improvements have provided a greater sense of depth, and faster computer processing has reduced latency between image capture and video output so that retinal procedures can now be routinely performed in a heads-up fashion working off the 3-D screen.3 In an experimental study, Eckardt and Paulo found the method to be well suited for heads-up surgery in vitreoretinal procedures.4 In their survey of 20 surgeons and a retrospective analysis of more than 400 vitrectomy cases, the authors noted that nearly 92% of the volunteers preferred the ergonomics of the heads-up technique. They deemed the heads-up technique and the traditional method to be similar as far as speed, ease of microscopic manipulations, and image sharpness. However, they noted that surgeons made significantly fewer mistakes with the heads-up method.4

The next opportunity for enhancing 3-D retinal surgery lies in digital image manipulation capabilities, which may allow surgeons to significantly reduce microscope illumination levels. In early use, the TrueVision 3D ICM5 camera’s high dynamic range function has allowed retinal surgeons to reduce microscope illumination by 80% or more while still producing excellent image quality for live surgery. This could be key in reducing retinal phototoxicity risk for patients.