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Three-Dimensional Visualization System for Vitreoretinal Surgery: Results from a Monocentric Experience and Comparison with Conventional Surgery

Fabrizio Giansanti
Cristina Nicolosi
Daniela Bacherini
Federica Soloperto
Federica Sarati
Dario Giattini
1,2 and
Giulio Vicini
Eye Clinic, Neuromuscular and Sense Organs Department, Careggi University Hospital, 50134 Florence, Italy
Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, 50121 Florence, Italy
Azienda USL Toscana Nord Ovest, 56121 Pisa, Italy
Author to whom correspondence should be addressed.
Life 2023, 13(6), 1289;
Submission received: 13 March 2023 / Revised: 11 May 2023 / Accepted: 24 May 2023 / Published: 31 May 2023
(This article belongs to the Collection New Diagnostic and Therapeutic Developments in Eye Diseases)


Purpose: To describe the experience of our centre (Careggi University Hospital, Florence, Italy) in using a heads-up three-dimensional (3D) surgical viewing system in vitreoretinal surgery, making a comparison with the conventional microscope surgery. Methods: We retrospectively analyzed data taken from 240 patients (240 eyes) with surgical macular diseases (macular hole and epiretinal membrane), retinal detachment or vitreous hemorrhage who underwent vitreoretinal surgeries, by means of the NGENUITY 3D Visualization System (Alcon Laboratories Inc., Fort Worth, TX, USA), in comparison with 210 patients (210 eyes) who underwent vitreoretinal surgeries performed using a conventional microscope. All surgeries were performed with standardized procedures by the same surgeons. We analyzed data over a follow-up period of 6 months, comparing the surgical outcomes (best-corrected visual acuity, anatomical success rate and postoperative complication rate) between the two groups. Results: the 3D group included 74 patients with retinal detachment, 78 with epiretinal membrane, 64 with macular hole and 24 with vitreous hemorrhage. There were no significant differences in the demographic and clinical characteristics between the 3D group and the conventional group. We found no significant differences in outcome measures at three and six months follow-up between the two groups (p-value ≥ 0.05 for all comparisons). Surgery durations were similar between the two groups. Conclusions: In our experience, a heads-up 3D surgical viewing system provided comparable functional and anatomical outcomes in comparison with conventional microscope surgery, proving to be a valuable tool for vitreoretinal surgery in the treatment of different retinal diseases.

1. Introduction

Since the introduction of three-dimensional (3D) visualization systems in vitreoretinal surgery, it has been increasingly employed by vitreoretinal surgeons, bringing a new ophthalmic microsurgery experience with periodically updated high-definition screen devices [1,2,3].
A 3D surgery system utilizes two high-definition dynamic cameras to record the image from different microscope viewing angles and a high-definition 3D display to receive a processed image [4]. It allows the surgeon to operate in a more comfortable position than a traditional microscope, meaning that they can raise their head up (the 3D system is, consequently, also known as a heads-up visualization system) and directly look at the surgical field on a large, high-definition 3D screen rather than a microscope eyepiece [1,4,5].
Some potential advantages of a 3D heads-up visualization system in comparison with a traditional microscope have been reported in different studies and include a higher-resolution visualization of the surgical field, higher magnification and digital processing of the image, more comfortable ergonomics for surgeons, and better surgical training, as all the people in the operating room can observe the same surgical field on the 3D display. The 3D viewing system enables the visualization on a single digital display of the imaging components (as intraoperative optical coherence tomography) and live details, such as the vitrectomy parameters, overlayed on the surgical field. Moreover, it may allow for the use of lower endoillumination parameters compared to a conventional microscope, compensated by a digital amplification of the camera signals, and possibly causing less retinal phototoxicity [1,5,6,7,8,9,10,11,12,13,14,15,16,17,18].
Different studies have been published on the application of 3D visualization systems in vitreoretinal surgery [1,5,17,19,20,21,22,23,24,25,26,27,28,29,30], but only a few studies have included large numbers of patients [24,25,26,27,29,30].
The aim of our study is to describe the experience of our center (Careggi University Hospital, Florence, Italy) concerning the application of a 3D visualization system in vitreoretinal surgery in a large series of patients affected by vitreoretinal surgical diseases when compared to conventional microscope surgery.

2. Materials and Methods

2.1. Subjects

We conducted a retrospective, comparative study at a single center (Ophthalmology department of Careggi University Hospital, Florence, Italy) over a period of 3 years. We analyzed patients affected by vitreoretinal diseases operated between January 2019 and January 2022, using either the NGENUITY System (3D group) or a traditional microscope (TM group). The surgical indicators included epiretinal membranes (ERMs), full-thickness macular holes (MHs), vitreous hemorrhage (VH), and rhegmatogenous retinal detachment (RRD).
A total of 450 patients were included in the study, distributed into the group undergoing surgery with the NGENUITY System (n = 240) and the group undergoing surgery that used conventional microscopy (n = 210).
The 3D group included 74 (30.8%) patients with RRD, 78 (32.5%) with idiopathic ERM, 64 (26.7%) with MH, and 24 (10%) with VH. The TM group included 65 (30.9%) patients with RRD, 67 (31.9%) with idiopathic ERM, 52 (24.8%) with MH, and 26 (12.4%) with VH. One hundred forty-four (60%) patients in the 3D group and 111 (52.9%) patients in the TM group underwent combined surgery with phacoemulsification and capsular bag intraocular lens implantation.

2.2. Methodology

Patients operated upon with the use of the 3D visualization system between January 2019 and January 2022, with a minimum 6 months follow-up, which were included in the study and were compared to patients operated upon using a traditional microscope, with a minimum 6 months follow-up, who were matched for pathology, sex, and age. The medical records of patients who underwent pars plana vitrectomy (PPV) for vitreoretinal diseases with the use of a 3D visualization system (3D group) or a traditional microscope (TM group) were reviewed. Patients with a postoperative follow-up of 6 months at least were included in the study. The review of medical records was approved by the Local Ethics Committee and adhered to the tenets of the declaration of Helsinki. All of the patients signed a written informed consent, agreeing to participate.
The surgeries were performed under local retrobulbar or general anesthesia by experienced vitreoretinal surgeons with standardized procedures. The surgical techniques did not differ between the 3D and TM groups. Three-port 25- or 23-gauge pars plana vitrectomy was performed with a CONSTELLATION Vision System (Alcon Laboratories, Fort Worth, TX, USA) using an aperture diaphragm of almost 1/2 to limit endoillumination exposure and optimize the visualization. All the surgical procedures were performed using an OPMI LUMERA 700 surgical microscope (Carl Zeiss Meditec, Jena, Germany) and a non-contact wide-angle RESIGHT viewing system (Zeiss, Oberkochen, Germany). The microscope eyepieces remained mounted for the TM group, and they were disassembled and replaced with the NGENUITY 3D visualization system (Alcon Laboratories), with the NGENUITY v1.4.31 software version, mounted on the microscope for the 3D group (Figure 1). The surgeon, the assistants, and the theatre nurses wore passive circularly polarized glasses to look at the surgical field on the 3D display.
Endoillumination light levels were initially set to 30–40% of maximum output for patients in the 3D group and 70–80% in the TM group, respectively. During the surgery, these levels were adjusted to optimize retinal visualization if necessary. Intraoperative Optical Coherence Tomography (OCT) was used during vitreomacular interface surgeries. Color filters were adjusted according to phacoemulsification and vitreoretinal surgery. The pre- and postoperative schemes were the same in both groups, and all employed a 23- or 25-gauge three-port pars plana vitrectomy technique. The surgical procedures varied based on the diagnosis. The inverted internal limiting membrane (ILM) flap technique was applied to eyes with MHs at the surgeon’s discretion. Endolaser was employed in the occurrence of retinal tears, RRD, and proliferative diabetic retinopathy. Fluid–air exchanges were performed when indicated. Endotamponade was performed with a balanced salt solution, air, gas, or silicon oil, which were employed according to the diagnosis. All the patients were administered topical antibiotics, corticosteroids, and anti-inflammatory eyedrops for 2 to 4 weeks postoperatively. The computerized operating registers extracted from our operating room report program allowed us to recover precise information concerning the surgical procedures and their duration, recorded by the equipe participating in each surgery. Two investigators (F.So. and F.Sa.) extracted the baseline and outcome data. The following patient information was extrapolated from the operating registers and from the medical records: age, gender, baseline lens status, diagnosis, surgical indication, ocular history, baseline best-corrected visual acuity (BCVA), 6-month postoperative BCVA, surgery duration, baseline anatomical data (macular hole diameter, ERM baseline central macular thickness, and RRD macular involvement) and surgical outcome data at 6 months from surgery. Pre- and postoperative BCVA was expressed as a decimal. Surgery duration was measured in minutes and was defined as the operation time from the first incision to the final removal of the blepharostat. MH diameter was defined by structural OCT, drawing with the caliper function a horizontal line connecting the two closest foveal points. ERM baseline central macular thickness was defined as the mean thickness within the central 1000 μm diameter area, calculated with the use of the OCT software on a thickness map. Macula-on RRD was defined as a condition where the fovea was not involved at the time of presentation.

2.3. Analysis

The surgical anatomical outcomes analyzed differed according to the surgical indication. They included the rate of MH closure (%), the rate of ERM removal (%), the rate of RRD reattachment (%), and the rate of VH clearing (%).
MH closure was defined as the flattening of MH with the absence of a neurosensory defect at the fovea. ERM removal was defined as complete ERM removal without signs of recurrence. RRD reattachment was defined as the complete reattachment of the retina. VH clearing was defined as the complete removal of blood within the vitreous cavity.
The structural and functional outcome endpoints used for effectiveness comparisons were based on anatomical outcomes, changes in BCVA, and surgery duration.
Statistical analysis was performed using IBM SPSS Statistics (IBM Corporation, Armonk, NY, USA) software for Mac (Version 26.0). Demographic and clinical data of the two groups, as well as the surgical outcomes, were compared using a two-tailed Student’s t-test or Chi-square test with 95% confidence intervals. Normal distribution of the data was determined using the Shapiro–Wilk test. The statistical significance was defined as a p-value of <0.05.

3. Results

No significant differences were found in the demographic and clinical data (age, gender, baseline lens status, surgical indications) between the 3D and TM groups. Additionally, the baseline anatomical characteristics of the different retinal diseases studied (MH diameter, ERM baseline central macular thickness, and RRD macular involvement) did not significantly differ between the patients in the 3D and TM groups. The demographic and clinical characteristics of the patients included in the study are summarized in Table 1.
No major intraoperative complications were encountered in both groups. No statistically significant differences were identified in outcomes analyzed during surgery follow-up between the 3D and TM groups. The surgical results data in 3D and TM groups are summarized in Table 2.
The rate of retinal reattachment of RRD in our study series was 92.1%, with a reattachment rate of 93.8% in the 3D group and 90.8% in the TM group (p-value = 0.59). The rate of MH closure at 3 months was 94%: 93.8% in the 3D group and 94.2% in the TM group (p-value = 0.91). The ERM removal was successful in both groups. Successful ERM removal was obtained in 100% of patients in both groups. Baseline BCVA was 0.36 in the 3D group and 0.41 in the TM group. There were no significant differences in the baseline and postoperative BCVA values between the two groups (p-value = 0.67 and 0.12, respectively). Both groups showed significant improvements in the mean BCVA at 6 months from surgery (p-value < 0.001).
Surgery durations were similar between both groups: 60.7 min in the 3D group and 61 min in the TM group (p-value = 0.46). Analysis of the different disease subgroups showed no significant differences (p-value ≥ 0.05 for all comparisons).

4. Discussion

In our study, we compared the outcome of 240 surgeries performed with the 3D Visualization System to 210 surgeries performed using conventional microscopy, selecting the same pathologies. We did not find any significant differences in overall visual outcomes (pre- and postoperative BCVA), anatomical outcomes (such as the removal of ERM, MH closure, retinal reattachment in RRD, and VH clearing), and surgery durations between the two groups. These results are in agreement with other studies, showing no significant differences in safety, anatomical outcomes and visual prognosis when comparing the usage of 3D visualization systems and conventional microscopes in the same vitreoretinal surgery techniques [1,20,21,22,23,24,25,26,27,28,29,30].
Regarding MH closure, the closure rate in our series was 93.99%, according to closure rates reported in the literature (90–100%), without significant differences between the two groups [31]. Guber et al. demonstrated a 91.9 µm reduction in central macular thickness at 3 months after vitrectomy in patients affected by primary ERM. The decrease of central macular thickness in ERMs was not statistically different in the two groups and was in line with the decrease in thickness reported at 3 months after vitrectomy in the literature [32].
Three-dimensional surgical visualization systems allow the ophthalmic surgeon to switch traditional microscope eyepieces with cameras transmitting an image on a high-definition display in front of them. Different advantages of a heads-up 3D visualization system over traditional microscopy have been described yet. First of all, the field depth has been reported to be similar or better in 3D systems in comparison to a traditional microscope because of the better light sensitivity of the software and the two high dynamic range cameras; the diaphragm aperture can be reduced, and the field depth increased [20,33,34]. The field depth is greater than the standard analog surgical microscope by 2–3 times if the opening of the NGENUITY system camera is reduced to 30%. This difference is not significant when the zoom level is high [34]. The dynamic range of the surgical images can be expanded by gain, gamma, and tone curve correction, uniformly adjusting the brightness and darkness of the image. High dynamic range cameras may combine multiple images from different points of view to improve the dynamic range balance of bright and dark areas of the same image, but they cannot manage image clouding or general hazes [35,36]. The sharpness is greater than conventional microscopes, and the surgeon requires less effort in terms of accommodation, especially older surgeons who have a smaller accommodative reserve [30]. It has been demonstrated that image-sharpening algorithms may ameliorate the clarity of all objects in the surgical field during combined cataract and vitreoretinal surgery using a 3D visualization system [37]. Image sharpening and color adjustments in real-time can enhance the intraoperative visibility in 3D surgery with the employment of the NGENUITY 3D Visualization System, by improving the contrast and ameliorating the image resolution, by narrowing the point spread function [37].
Moreover, the 3D image is achieved through the combination of two high dynamic range camera images, which are processed by algorithms, allowing for the magnification of lower light levels [30]. Endoillumination levels are also reduced, preserving adequate visualization. Therefore, decreased endoillumination reduces retinal light exposure during surgeries and retinal phototoxicity, especially during macular surgery, for example, by keeping the light source at a greater distance from the retina [37].
In relation to the facility of employment of the NGENUITY 3D Visualization System, the opinions of surgeons have been previously analyzed with satisfaction questionnaires by comparing fine surgical tasks [22,38]. These satisfactory questionnaires also showed an improvement in comfort, a more ergonomic position and a reduction in back and neck pain, which is frequently detected among ophthalmologic surgeons [22,38,39]. The different ergonomics and head and neck positions of the ophthalmic surgeon in the employment of both a 3D visualization system and a conventional microscopy configuration are shown in Figure 2.
Regarding surgical training and education, there are some advantages to using a 3D visualization system. All the people present in an operating theatre can look at the same live surgical field image, conversely to the conventional microscope, in which only the first and second operators can look at the surgical field in a high-definition way. Additionally, the first operator can teach more than one trainee intern at the same time, as shown in Figure 3. The 3D image can also be recorded and retransmitted at a distance or live, and surgical video streaming can be achieved in real-time with minimal latency through video capture equipment and video conferencing/streaming software [1,40,41,42].
The employment of heads-up 3D visualization system technology in vitreoretinal surgery has been reported to be effective, but only a few published studies have included large numbers of patients [24,25,26,27,29,30]. Different studies that have compared heads-up 3D viewing system technology with conventional microscopes in vitreoretinal surgery found similar anatomical and functional outcomes in addition to comparable surgical efficiency (Table 3).
Asani et al. compared PPV for rhegmatogenous retinal detachment using either the NGENUITY 3D Visualization System (n = 70) or a standard operating microscope (n = 70), yielding similar results in terms of anatomical and functional outcomes (primary retinal reattachment rate, rate of proliferative vitreoretinopathy, and final BCVA); however, surgery time was slightly longer in the 3D group (REF). Interestingly, this result was evident when looking at the first 35 cases, but it was not reproducible when only comparing the latest 35 cases against each other, suggesting the effect of the learning curve required for the 3D platform [30]. Another study conducted by Talcott et al. indicates a learning curve for the 3D platform. This was a prospective randomized study that reported a series of 39 patients undergoing PPV with peeling for macular pathology, including ERM and MH. Although the overall surgical times were similar, the macular peel times in the 3D group were longer and associated with less ease of use in this study, which may partly be due to a learning curve required for the use of 3D technology [21].
The study conducted by Zhao et al. showed different results, with the duration of ERM or ILM peeling for eyes with ERM and idiopathic MH significantly shorter in the 3D group than in the conventional microscope group. This result was associated with significantly shorter general surgical duration for eyes with ERM and idiopathic MH. The authors suggest that one possible reason could be that the 3D heads-up surgery has the advantage of high image magnification at a wider visual field compared with the conventional microscope, which enables surgeons to view the fine structures of the retina and then perform membrane peeling more precisely [27].
In our series, we found similar values in the duration of surgery, both considering the overall series and the different pathologies, in agreement with most of the literature. Although we did not record the ERM or ILM peeling time in our study, no differences were documented in the mean duration of the complete operations for ERM and MH in the two groups.
In summary, we reported the clinical surgical outcomes of 3D visualization system for vitreoretinal diseases in a large series of patients operated at a single center. In our series, the heads-up 3D visualization system appears to be comparable to traditional surgical microscopy in terms of effectiveness and safety in the treatment of RRD, ERM, MH, and VH. The visual and anatomical outcomes and the surgery duration were not statistically different from those of traditional microscope vitrectomies for the different surgical indicators. Our findings need to be confirmed in further prospective, randomized studies.

5. Conclusions

In conclusion, in our experience, the 3D heads-up visualization system can be considered a valuable and safe tool for vitreoretinal surgery, but further prospective, randomized studies are required to confirm these preliminary findings.

Author Contributions

Conceptualization, F.G., C.N., D.B. and G.V.; Methodology, F.G., C.N., D.B. and G.V.; Software, F.G., C.N. and G.V.; Validation, F.G., C.N., D.B. and G.V., Formal analysis, F.G., C.N., D.B. and G.V.; Investigation, F.G., C.N., D.B., F.S. (Federica Soloperto), F.S. (Federica Sarati) and G.V.; Resources, F.G., C.N., D.B. and G.V.; Data curation, F.G., C.N., F.S. (Federica Soloperto), F.S. (Federica Sarati), D.G. and G.V.; Writing—original draft preparation, F.G., C.N., D.B., F.S. (Federica Soloperto), F.S. (Federica Sarati), D.G. and G.V.; Writing—review and editing, F.G., C.N., D.B., F.S. (Federica Soloperto), F.S. (Federica Sarati), D.G. and G.V.; Visualization, F.G., C.N., D.B., D.G. and G.V.; Supervision, G.V.; Project administration, G.V. All authors have read and agreed to the published version of the manuscript.


This research received no external funding.

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki, and approved by the Institutional Review Board of Careggi University Hospital. Ethic Committee Name: Careggi Hospital, Ethic Committee Area Vasta Centro. Approval Code: OSS.16.173. Approval Date: 21 November 2016.

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

The data presented in this study are available upon request from the corresponding author.

Conflicts of Interest

The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results.


  1. Eckardt, C.; Paulo, E.B. Heads-up surgery for vitreoretinal procedures: An experimental and clinical study. Retina 2016, 36, 137–147. [Google Scholar] [CrossRef] [PubMed]
  2. Figueroa, M.S. 3D vitrectomy. Is it really useful? Arch. Soc. Esp. Oftalmol. 2017, 92, 249–250. [Google Scholar] [CrossRef] [PubMed]
  3. Moura-Coelho, N.; Henriques, J.; Nascimento, J.; Dutra-Medeiros, M. Three-Dimensional Display Systems in Ophthalmic Surgery—A Review. Eur. Ophthalmic Rev. 2019, 13, 31. [Google Scholar] [CrossRef]
  4. Liu, J.; Wu, D.; Ren, X.; Li, X. Clinical Experience of Using the NGENUITY Three-Dimensional Surgery System in Ophthalmic Surgical Procedures. Acta Ophthalmol. 2021, 99, e101–e108. [Google Scholar] [CrossRef] [PubMed]
  5. Rizzo, S.; Abbruzzese, G.; Savastano, A.; Giansanti, F.; Caporossi, T.; Barca, F.; Faraldi, F.; Virgili, G. 3D SURGICAL VIEWING SYSTEM IN OPHTHALMOLOGY: Perceptions of the Surgical Team. Retina 2018, 38, 857–861. [Google Scholar] [CrossRef]
  6. Weinstock, R.J.; Diakonis, V.F.; Schwartz, A.J.; Weinstock, A.J. Heads-up Cataract Surgery: Complication Rates, Surgical Duration, and Comparison with Traditional Microscopes. J. Refract. Surg. 2019, 35, 318–322. [Google Scholar] [CrossRef]
  7. Wang, K.; Song, F.; Zhang, L.; Xu, J.; Zhong, Y.; Lu, B.; Yao, K. Three-Dimensional Heads-up Cataract Surgery Using Femtosecond Laser: Efficiency, Efficacy, Safety, and Medical Education-A Randomized Clinical Trial. Transl. Vis. Sci. Technol. 2021, 10, 4. [Google Scholar] [CrossRef]
  8. Rosenberg, E.D.; Nuzbrokh, Y.; Sippel, K.C. Efficacy of 3D Digital Visualization in Minimizing Coaxial Illumination and Phototoxic Potential in Cataract Surgery: Pilot Study. J. Cataract Refract. Surg. 2021, 47, 291–296. [Google Scholar] [CrossRef]
  9. Qian, Z.; Wang, H.; Fan, H.; Lin, D.; Li, W. Three-Dimensional Digital Visualization of Phacoemulsification and Intraocular Lens Implantation. Indian J. Ophthalmol. 2019, 67, 341–343. [Google Scholar] [CrossRef] [PubMed]
  10. Nariai, Y.; Horiguchi, M.; Mizuguchi, T.; Sakurai, R.; Tanikawa, A. Comparison of Microscopic Illumination between a Three-Dimensional Heads-up System and Eyepiece in Cataract Surgery. Eur. J. Ophthalmol. 2021, 31, 1817–1821. [Google Scholar] [CrossRef] [PubMed]
  11. Kelkar, J.A.; Kelkar, A.S.; Bolisetty, M. Initial Experience with Three-Dimensional Heads-up Display System for Cataract Surgery—A Comparative Study. Indian J. Ophthalmol. 2021, 69, 2304–2309. [Google Scholar] [CrossRef]
  12. Del Turco, C.; D’Amico Ricci, G.; Dal Vecchio, M.; Bogetto, C.; Panico, E.; Giobbio, D.C.; Romano, M.R.; Panico, C.; la Spina, C. Heads-up 3D Eye Surgery: Safety Outcomes and Technological Review after 2 Years of Day-to-Day Use. Eur. J. Ophthalmol. 2022, 32, 1129–1135. [Google Scholar] [CrossRef] [PubMed]
  13. Berquet, F.; Henry, A.; Barbe, C.; Cheny, T.; Afriat, M.; Benyelles, A.K.; Bartolomeu, D.; Arndt, C. Comparing Heads-Up versus Binocular Microscope Visualization Systems in Anterior and Posterior Segment Surgeries: A Retrospective Study. Int. J. Ophthalmol. 2020, 243, 347–354. [Google Scholar] [CrossRef] [PubMed]
  14. Bedar, M.S.; Kellner, U. Digital 3D “Heads-up” Cataract Surgery: Safety Profile and Comparison with the Conventional Microscope System. Klin. Mon. Augenheilkd. 2022, 239, 991–995. [Google Scholar] [CrossRef]
  15. Bawankule, P.; Narnaware, S.; Chakraborty, M.; Raje, D.; Phusate, R.; Gupta, R.; Rewatkar, K.; Chivane, A.; Sontakke, S. Digitally Assisted Three-Dimensional Surgery—Beyond Vitreous. Indian J. Ophthalmol. 2021, 69, 1793–1800. [Google Scholar] [CrossRef]
  16. Kelkar, A.; Kelkar, J.; Chougule, Y.; Bolisetty, M.; Singhvi, P. Cognitive Workload, Complications and Visual Outcomes of Phacoemulsification Cataract Surgery: Three-Dimensional versus Conventional Microscope. Eur. J. Ophthalmol. 2022, 32, 2935–2941. [Google Scholar] [CrossRef] [PubMed]
  17. Agranat, J.S.; Miller, J.B.; Douglas, V.P.; Douglas, K.A.A.; Marmalidou, A.; Cunningham, M.A.; Houston, S.K., 3rd. The Scope Of Three-Dimensional Digital Visualization Systems In Vitreoretinal Surgery. Clin. Ophthalmol. 2019, 13, 2093–2096. [Google Scholar] [CrossRef]
  18. Bin Helayel, H.; Al-Mazidi, S.; Al Akeely, A. Can the Three-Dimensional Heads-Up Display Improve Ergonomics, Surgical Performance, and Ophthalmology Training Compared to Conventional Microscopy? Clin. Ophthalmol. 2021, 15, 679–686. [Google Scholar] [CrossRef]
  19. Coppola, M.; La Spina, C.; Rabiolo, A.; Querques, G.; Bandello, F. Heads-up 3D vision system for retinal detachment surgery. Int. J. Retina Vitreous. 2017, 3, 46. [Google Scholar] [CrossRef]
  20. Romano, M.R.; Cennamo, G.; Comune, C.; Cennamo, M.; Ferrara, M.; Rombetto, L.; Cennamo, G. Evaluation of 3D heads-up vitrectomy: Outcomes of psychometric skills testing and surgeon satisfaction. Eye 2018, 32, 1093–1098. [Google Scholar] [CrossRef]
  21. Talcott, K.E.; Adam, M.K.; Sioufi, K.; Aderman, C.M.; Ali, F.S.; Mellen, P.L.; Garg, S.J.; Hsu, J.; Ho, A.C. Comparison of a three-dimensional heads-up display surgical platform with a standard operating microscope for macular surgery. Ophthalmol. Retina 2019, 3, 244–251. [Google Scholar] [CrossRef] [PubMed]
  22. Palácios, R.M.; de Carvalho, A.C.M.; Maia, M.; Caiado, R.R.; Camilo, D.A.G.; Farah, M.E. An experimental and clinical study on the initial experiences of Brazilian vitreoretinal surgeons with heads-up surgery. Graefes Arch. Clin. Exp. Ophthalmol. 2019, 257, 473–483. [Google Scholar] [CrossRef] [PubMed]
  23. Kumar, A.; Hasan, N.; Kakkar, P.; Mutha, V.; Karthikeya, R.; Sundar, D.; Ravani, R. Comparison of clinical outcomes between ‘heads-up’ 3D viewing system and conventional microscope in macular hole surgeries: A pilot study. Indian J. Ophthalmol. 2018, 66, 1816–1819. [Google Scholar] [CrossRef] [PubMed]
  24. Zhang, T.; Tang, W.; Xu, G. Comparative analysis of three-dimensional heads-up vitrectomy and traditional microscopic vitrectomy for vitreoretinal diseases. Curr. Eye Res. 2019, 44, 1080–1086. [Google Scholar] [CrossRef] [PubMed]
  25. Palácios, R.M.; Kayat, K.V.; Morel, C.; Conrath, J.; Matonti, F.; Morin, B.; Farah, M.E.; Devin, F. Clinical study on the initial experiences of French vitreoretinal surgeons with heads-up surgery. Curr. Eye Res. 2020, 45, 1265–1272. [Google Scholar] [CrossRef]
  26. Kantor, P.; Matonti, F.; Varenne, F.; Sentis, V.; Pagot-Mathis, V.; Fournié, P.; Soler, V. Use of the heads-up NGENUITY 3D Visualization System for vitreoretinal surgery: A retrospective evaluation of outcomes in a French tertiary center. Sci. Rep. 2021, 11, 10031. [Google Scholar] [CrossRef] [PubMed]
  27. Zhao, X.Y.; Zhao, Q.; Li, N.N.; Meng, L.H.; Zhang, W.F.; Wang, E.Q.; Chen, Y.X. Surgery-related characteristics, efficacy, safety and surgical team satisfaction of three-dimensional heads-up system versus traditional microscopic equipment for various vitreoretinal diseases. Graefes Arch. Clin. Exp. Ophthalmol. 2023, 261, 669–679. [Google Scholar] [CrossRef]
  28. Nowomiejska, K.; Toro, M.D.; Bonfiglio, V.; Czarnek-Chudzik, A.; Brzozowska, A.; Torres, K.; Rejdak, R. Vitrectomy combined with cataract surgery for retinal detachment using a three-dimensional viewing system. J. Clin. Med. 2022, 11, 1788. [Google Scholar] [CrossRef]
  29. Zeng, R.; Feng, Y.; Begaj, T.; Baldwin, G.; Miller, J.B. Comparison of the Safety and Efficacy of a 3-Dimensional Heads-up Display vs a Standard Operating Microscope in Retinal Detachment Repair. J. Vitreoretin. Dis. 2023, 7, 97–102. [Google Scholar] [CrossRef]
  30. Asani, B.; Siedlecki, J.; Schworm, B.; Mayer, W.J.; Kreutzer, T.C.; Luft, N.; Priglinger, S.G. 3D Heads-Up Display vs. Standard Operating Microscope Vitrectomy for Rhegmatogenous Retinal Detachment. Front. Med. 2020, 7, 615515. [Google Scholar] [CrossRef]
  31. Parravano, M.; Giansanti, F.; Eandi, C.M.; Yap, Y.C.; Rizzo, S.; Virgili, G. Vitrectomy for idiopathic macular hole. Cochrane Database Syst. Rev. 2015, 2015, CD009080. [Google Scholar] [CrossRef] [PubMed]
  32. Guber, J.; Pereni, I.; Scholl, H.P.N.; Guber, I.; Haynes, R.J. Outcomes after epiretinal membrane surgery with or without internal limiting membrane peeling. Ophthalmol. Ther. 2019, 8, 297. [Google Scholar] [CrossRef] [PubMed]
  33. Palácios, R.M.; Maia, A.; Farah, M.E.; Maia, M. Learning curve of three-dimensional heads-up vitreoretinal surgery for treating macular holes: A prospective study. Int. Ophthalmol. 2019, 39, 2353–2359. [Google Scholar] [CrossRef] [PubMed]
  34. Freeman, W.R.; Chen, K.C.; Ho, J.; Chao, D.L.; Ferreyra, H.A.; Tripathi, A.B.; Nudleman, E.; Bartsch, D.-U. resolution, depth of field, and physician satisfaction during digitally assisted vitreoretinal surgery. Retina 2019, 39, 1768–1771. [Google Scholar] [CrossRef]
  35. Reinhard, E.; Heidrich, W.; Debevec, P.; Pattanaik, S.; Ward, G.; Myszkowski, K. High Dynamic Range Imaging: Acquisition, Display, and Image-Based Lighting, 2nd ed.; Morgan Kauffman Publisher: Burlington, MA, USA, 2010; pp. 91–117. [Google Scholar]
  36. Seetzen, H.; Heidrich, W.; Stuerzlinger, W.; Ward, G.; Whitehead, L.; Trentacoste, M.; Ghosh, A.; Vorozcovs, A. High dynamic range display systems. ACM Trans. Graph. 2004, 23, 760–768. [Google Scholar] [CrossRef]
  37. Franklin, A.J.; Sarangapani, R.; Yin, L.; Tripathi, B.; Riemann, C. Digital vs. Analog Surgical Visualization for Vitreoretinal Surgery. Retinal Physician. 2017. Available online: (accessed on 3 February 2023).
  38. Nakajima, K.; Inoue, M.; Mizuno, M.; Koto, T.; Ishida, T.; Ozawa, H.; Oshika, T. Effects of image-sharpening algorithm on surgical field visibility during 3D heads-up surgery for vitreoretinal diseases. Sci. Rep. 2023, 13, 2758. [Google Scholar] [CrossRef] [PubMed]
  39. Hyer, J.; Lee, R.M.; Chowdhury, H.R.; Smith, H.B.; Dhital, A.; Khandwala, M. National survey of back & neck pain amongst consultant ophthalmologists in the United Kingdom. Int. Ophthalmol. 2015, 35, 769–775. [Google Scholar]
  40. Nakajima, K.; Inoue, M.; Mizuno, M.; Koto, T.; Ishida, T.; Ozawa, H.; Oshika, T. Minimal endoillumination levels and display luminous emittance during three-dimensional heads-up vitreoretinal surgery. Retina 2017, 37, 1746–1749. [Google Scholar]
  41. Lu, E.S.; Reppucci, V.S.; Houston, S.K.S., 3rd; Kras, A.L.; Miller, J.B. Three-dimensional telesurgery and remote proctoring over a 5G network. Digit. J. Ophthalmol. 2021, 27, 38–43. [Google Scholar] [CrossRef]
  42. Seddon, I.A.; Rahimy, E.; Miller, J.B.; Charles, S.; Kitchens, J.; Houston, S.K., 3rd. Feasibility and Potential for Real-Time 3D Vitreoretinal Surgery Telementoring. Retina, 2022; Epub ahead of print. [Google Scholar] [CrossRef]
Figure 1. Our operating theatre configuration with the NGENUITY 3D Visualization System.
Figure 1. Our operating theatre configuration with the NGENUITY 3D Visualization System.
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Figure 2. The images show the better ergonomics of the 3D visualization system for the surgeon (a), in comparison with the conventional microscopy configuration (b).
Figure 2. The images show the better ergonomics of the 3D visualization system for the surgeon (a), in comparison with the conventional microscopy configuration (b).
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Figure 3. Interns surgical training, as all the people in the operating room can observe the same surgical field on the 3D display.
Figure 3. Interns surgical training, as all the people in the operating room can observe the same surgical field on the 3D display.
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Table 1. Demographic and clinical characteristics of the patients included in the study.
Table 1. Demographic and clinical characteristics of the patients included in the study.
3D GroupTraditional Microscope Groupp-Value
Number of patients, n240210
Age, years (mean ± SD)59.3 ± 12.161.7 ±13.30.075 *
Sex, n (%) 0.63 **
Male149 (62.1%)135 (64.3%)
Female91 (37.9%)75 (35.7%)
Lens status, n (%) 0.41 **
Phakia144 (60%)111 (52.9%)
Pseudophakia96 (40%)99 (47.1%)
Indications, n (%) 0.86 **
Retinal detachment74 (30.8%)65 (30.9%)
Idiopathic epiretinal membrane78 (32.5%)67 (31.9%)
Macular hole64 (26.7%)52 (24.8%)
Vitreous hemorrhage24 (10%)26 (12.4%)
Macular hole diameter, µm (mean ± SD)374.2 ± 125.3392.75 ± 139.3 0.45 *
Epiretinal baseline central macular thickness, µm (mean ± SD)438.75 ± 125.8 441.67 ± 81.2 0.52 *
Retinal detachment macular involvement, n (%)39 (52.7%)32 (49.2%)0.68 **
Baseline decimal BCVA (mean)0.360.41 0.67 *
BCVA = best-corrected visual acuity; * Student’s t-test; ** Chi-square test.
Table 2. Surgical results of patients included in the study.
Table 2. Surgical results of patients included in the study.
3D Group
(N = 240)
Traditional Microscope Group
(N = 210)
Post-op decimal BCVA (mean)0.530.570.12 *
Surgery time, minutes (mean)60.761.00.46 *
Retinal detachment time, minutes (mean)69670.26 *
Idiopathic epiretinal membrane time, minutes (mean)57.656.60.74 *
Macular hole time, minutes (mean)56.1458.10.86 *
Vitreous hemorrhage time, minutes (mean)57.0563.00.16 *
Surgical outcome ***
ERM removal, %100100-
MH closure, %93.894.20.91 **
Retinal reattachment, % **
VH clearing, %95.896.10.95 **
BCVA = best-corrected visual acuity; * Student’s t-test; ** Chi-square test; *** at 6-month follow-up.
Table 3. Studies reported in literature regarding the comparison of heads-up 3D visualization system technology with conventional microscope in vitreoretinal surgery.
Table 3. Studies reported in literature regarding the comparison of heads-up 3D visualization system technology with conventional microscope in vitreoretinal surgery.
AuthorsNumber of Patients 3D Group/CM GroupType of Treatment/
Surgical Indication
Kumar et al. [23]25/25PPV with multilayered inverted ILM membrane flap technique and 20% SF6 for FTMHPre- and postoperative BCVA, macular hole index, total surgical time, total ILM peel time, number of flap initiations, duration of Brilliant Blue G dye exposure, and illumination intensityComparable clinical outcomes. Illumination intensity of microscope and endoillumination were significantly less in the 3D group
Talcott et al. [21]23/16PPV for ERM and FTMHTotal operative time, macular peel time, surgeon rating of viewing system ease of use, minimum required endoillumination, intraoperative complication rate, and postoperative BCVANo significant difference in overall operative time, but macular peel time was significantly longer using 3D HUD and associated with less ease of use. The minimum required endoillumination was significantly lower with 3D HUD. No significant differences in BCVA and complication occurrence
Zhang et al. [24]124/202PPV for RRD, FTMH, ERM, VH, VO, SOR, and MFPre- and postoperative BCVA, ERM removal
VH clearing, MH closure, RD reattachment, MF resolution, SOR success, VO clearing, operation time, postoperative complications occurrence
Comparable visual and anatomical outcomes without a significant difference in the rate of complications
Palácios et al. [33]94/94PPV for RRD and MHSurgeon preference was assessed using a questionnaire, anatomical success rateComparable anatomical outcomes
Asani et al. [30]70/70PPV for RRDPrimary retinal reattachment rate, rate of proliferative vitreoretinopathy, final BCVA, duration of surgeryComparable anatomical and functional outcomes. Duration of surgery was significantly longer in the 3D group, an effect which, however, vanished after a “learning curve” of the first 35 eyes
Kantor et al. [26]131/96PPV for RRD, FTMH, and ERMPrimary endpoints: recurrence rates of RD, FTMH closure rates, reduction in central macular thickness in ERMs at 3 months after surgery. Secondary endpoints: surgery durations, 3-month postoperative BCVAComparable visual and anatomical outcomes
Zhao et al. [27]220/242PPV for RRD, TRD, FTMH, ERM, VMT, VH, VO, SOR, and MFBCVA, primary anatomical success (varied according to the surgical indicators), general surgical duration, duration of specific surgical steps, perioperative complications, and satisfaction feedback from the surgical team Comparable efficacy and safety. Shorter duration of ERM or ILM peeling for the 3D HUD group with significantly shorter general surgical duration for ERM and MH surgery. Better surgical team satisfaction
Nowomiejska et al. [28]26/56PPV combined with cataract surgery for RRDBCVA, surgery duration, rate of postoperative complicationsNo significant differences in surgery duration, rate of complications, and functional results
Zeng et al. [29]50/138PPV alone or combined PPV and scleral buckle for RRDAnatomic success rate, rate of postoperative proliferative vitreoretinopathy, surgery durationAnatomical and functional outcomes and surgical efficiency comparable in the two groups
PPV: pars plana vitrectomy; ILM: internal limiting membrane; FTMH: full-thickness macular hole; BCVA: best-corrected visual acuity; ERM: epiretinal membrane; 3D HUD: 3D heads-up display; RRD: rhegmatogenous retinal detachment; VH: vitreous hemorrhage; VO: vitreous opacities; SOR: silicone oil removal; MF: pathologic myopic foveoschisis; TRD: tractional retinal detachment; VMT: vitreomacular traction syndrome.
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MDPI and ACS Style

Giansanti, F.; Nicolosi, C.; Bacherini, D.; Soloperto, F.; Sarati, F.; Giattini, D.; Vicini, G. Three-Dimensional Visualization System for Vitreoretinal Surgery: Results from a Monocentric Experience and Comparison with Conventional Surgery. Life 2023, 13, 1289.

AMA Style

Giansanti F, Nicolosi C, Bacherini D, Soloperto F, Sarati F, Giattini D, Vicini G. Three-Dimensional Visualization System for Vitreoretinal Surgery: Results from a Monocentric Experience and Comparison with Conventional Surgery. Life. 2023; 13(6):1289.

Chicago/Turabian Style

Giansanti, Fabrizio, Cristina Nicolosi, Daniela Bacherini, Federica Soloperto, Federica Sarati, Dario Giattini, and Giulio Vicini. 2023. "Three-Dimensional Visualization System for Vitreoretinal Surgery: Results from a Monocentric Experience and Comparison with Conventional Surgery" Life 13, no. 6: 1289.

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