Commentary: Digitally assisted vitreoretinal surgery - Redefining vitreo-retina fellowship training

Gone are the days when vitreoretinal fellows used to stand in a queue to get a glimpse of the complex procedures in the side scope of an analog microscope. This study aims at finding out the relevance of the DAVS platform used in the NGENUITY 3D Visualization System (Alcon, Forth Worth, Texas, USA) along with TrueVision Visualization System (Santa Barbara, California, USA) in surgical steps visualization compared to the conventional analog microscope (CAM).

The 3D DAVS visualization system offers a ‘‘heads-up’’ position for the operating surgeon. This system also has high image definition at wider magnifications and can be used at much lower endo-illumination levels compared to the CAM. Moreover, DAVS allows a “surgeon’s view” to the students, scrub nurse/fellow, and anesthesiologist present in the room. Additionally, it allows the scrub nurse/fellow to be in sync with the surgeon, who can anticipate the next steps during the procedure. As a result, this platform can be made an integral component in fellow and resident education.

In this study of IJO, the authors have concluded that the DAVS system has an advantage to the observers in terms of comfort, image quality, understanding of surgery, and viewing preference.[1]

Few additional factors need to be considered while interpreting the results of this study.

Here, each study participant watched a minimum of five surgeries on each of the two platforms comprising three categories of vitreoretinal procedures. It would have been interesting to see the response of fellows or students actively assisting the surgeon during vitreoretinal surgical procedures, such as during scleral or belt buckling, holding contact lenses, or during scleral depression. During vitreoretinal surgery, in most cases, the assistant sits on the right or left side of the patient, facing the patient sidewise. In the DAVS platform, they have to turn to the right or left to see the screen. This would inevitably increase their fatigue and discomfort, jeopardizing active assistance during those surgeries.

There are reports where it was depicted that in sufficiently long surgeries, the surgeon must move to relax his/her neck. The television display is always slightly lateralized, causing a negative impact ergonomically, resulting in torticollis. Furthermore, it was noted that people (other than the surgeon) who were not being able to view the display on the same axis had complaints of dizziness or nausea.[2]

3D asthenopia, such as dizziness, after viewing 3D displays is not very uncommon. Wee et al.[1] found that accommodation and binocular vergence may also influence 3D asthenopia significantly.[3]

DAVS platform has an initial high expense as currently both the surgical microscope and the 3D technology need to be purchased separately instead of only the operating microscope, which is being used in CAM. There are reports of future developments that aim to have an integrated, stand-alone DAVS system. On the downside, the 3D system has a larger footprint compared to an operating microscope alone; thus, there needs to be significant physical space in the operating room for the anesthesiologists and nurses to maneuver the anesthesia apparatus and vitrectomy machine around the display monitor in a non-obstructing manner.[4]

To get a solution, Yoshihiro et al.[5] suggested a microscope-independent camera that can slide over the patient; if developed, it would cause fewer concerns related to positioning and visual obstructions. This would also help in achieving a smaller footprint in the operating room.

There is no doubt that the modern vitreoretinal surgical instruments and microscopes have made a paradigm shift in understanding and adopting the nuances of surgical techniques both for the surgeons as well as the trainees. DAVS platform has undeniably changed the perspective of viewing the operating field, and the authors in this article have made their very valid comparisons. More number of participants, a more detailed questionnaire, and varied surgeries with a longer time frame would have made this study’s results more intriguing. This system, though having its own certain limitations, is definitely going to change the way of ophthalmic surgical training in the coming days.