ESCRS - High-Tech Eye Tech
ESCRS - High-Tech Eye Tech

High-Tech Eye Tech

Head-up 3D helmet could increase surgical precision while enhancing surgeon comfort. Howard Larkin reports.

High-Tech Eye Tech
Howard Larkin
Howard Larkin
Published: Monday, July 4, 2022

Surgeons have been hunching over their operating microscopes for a century, suffering lifelong ergonomic problems as they treat their patients. Now, with the appearance of digital microscopy and heads-up displays, relief may be at hand.

After more than 15 years of anterior segment ophthalmic surgery, Jonathan D Solomon MD has made a big investment in preserving his neck and back – and his future practice. He and a partner have purchased a Beyeonics One™ digital surgical exoscope for a new surgery centre they are building near Washington, DC, USA.

The digital device’s 3D visor allows Dr Solomon to hold his head up straight and relax during surgery, he explained. “I have to be a little bit more focused now on my ergonomics. Before, being younger, I could muscle on through. But now, after a day or two of surgery, my body starts to feel it.”

As a taller surgeon, Dr Solomon has always had difficulty getting comfortable behind an analogue binocular surgical microscope. It is hard to get the operating table high enough to fit his legs, and he has to slump to reach both the patient and the oculars.

Digitally enhanced 3D imaging and data overlays available on big-screen displays make surgery easier and possibly safer, Dr Solomon said. So, he was an early adopter of head-up surgical technology.

But while large-screen 3D displays definitely help, they still have to be set up in a particular place to maintain a consistent view of the surgical field, limiting surgeon movement and OR setup flexibility. The visor is an improvement because it projects a 3D image from one temporal field to the other regardless of head position, making it both more immersive and more relaxing.

“Now [the surgical field image] is anywhere you turn your head. Everything downstream tends to relax, your lower body relaxes, your lower back relaxes, your neck and shoulders tend to drop. It takes it to the next level, delivering what was initially intended when we went to a 3D television,” said Dr Solomon, who has done about 50 procedures with the visor.

The visor’s digitally enhanced image also increases depth of field, making fewer changes of focus necessary and enhancing visualisation of tissue planes and edges, Dr Solomon added. The device can be programmed to activate functions with head gestures or pedal movements. Producing the digital image also requires less light than direct visualisation, potentially reducing the risk of retinal light damage.

“As somebody who has used a lot of 3D systems – you name it, I’ve used it – from the vantage point of the surgeon, the ergonomics, the image quality – there is just nothing I’ve seen to date that even compares,” Dr Solomon said.


Dr Solomon is far from alone in his concern for his neck and back health. In a 2005 study of musculoskeletal symptoms in USA ophthalmologists, 51% reported neck or back pain, and 15% limited their work as a result.i In a similar 1994 UK study, 54% reported back pain, with those longest in the field having it more frequently.ii

A 2011 study of ophthalmic plastic surgeons found 72.5% had pain associated with operating, causing 42.5% to modify their operating room practice and 9.2% to stop operating altogether.iii

Indeed, in a presentation on head-up displays at the 2022 ASCRS Annual Meeting, Nicole R Fram MD showed a neck scan of one of her older partners, showing compressed cervical vertebrae. “I want to emulate him in every way, but not this way.”

Dr Fram’s practice investigated three head-up systems, noting strengths and weaknesses of each. The Alcon Ngenuity® system attaches to any microscope, integrates diagnostic and other patient data, and displays ORA intraoperative aberrometry. However, it has a large footprint, so integrating it into the operating theatre required getting everyone on board, though “being able to see everything in front of you on this big screen is great for you and the team.”

Advantages of the Zeiss Artevo 800 system include two 4K cameras, integration with the microscope offering a hybrid mode with oculars, and intraoperative OCT, but it also has a large footprint. Dr Fram showed a video of removing interface fluid during a DSAEK, watching it in real time on OCT. “I’ve never seen this in real time, so this is amazing.”

The BVI Beyeonics headset has a small footprint and allows for easy adaption, Dr Fram said. “It was really easy to implement, but the red reflex and saturation are different and are being optimised to reflect our current microscope experience.” By contrast, Dr Solomon feels it offers better visualisation of tissue planes and edges.

Dr Fram noted that head-up surgical technology is still in its infancy and will continue to develop. “The winning technology will be the one that has data integration but also the smallest footprint,” she said.


Presenting on behalf of Robert J Weinstock and colleagues at the 2022 ASCRS Annual Meeting, Caroline Watson MD reported on a study comparing the Beyeonics One with an Alcon Ngenuity and a conventional binocular analogue microscope for manual and femtosecond laser-assisted cataract surgery using singlepiece monofocal and multifocal non-toric lenses. For a total of 533 eyes of 412 patients operated by one experienced surgeon and two inexperienced surgeons, surgical times were similar among the three groups, nor were any significant differences reported for manual cataract surgery or FLACS. No complications were reported in any of the 533 cases.

These results were similar to those reported by Dr Weinstock and colleagues in a 2019 study comparing a 3D head-up screen system with manual surgery on 2,320 consecutive surgeries, which found no difference in surgical time and similarly low complication rates.iv However, another series involving 343 eyes found a 3D external display system added nearly two minutes to surgical time compared with manual surgery, though safety outcomes were similar.v

“Heads-up cataract surgery may assist in avoiding development of occupational musculoskeletal injuries,” Dr Watson said. The 3D visualisation systems also offer a much better teaching tool for early surgical training, she added.

Dr Fram noted that adjusting to a headup system takes some effort. But surgeon’s necks are worth the discomfort of adapting to a new way to operate. “We really need to worry about this, whether it is difficult or easy, because it is the wave of the future,” she said.

The Beyeonics systems are now available in the USA. In Europe, enrolment of evaluation and training sites for the device is scheduled to begin early next year.

American Journal of Ophthalmology. 2005; 139: 179–181.

ii Eye (London) 1994; 8(Pt 4): 473–4.

iii Ophthalmic Plastic and Reconstructive Surgery. Jan–Feb 2011; 27(1): 28–32.

iv Journal of Refractive Surgery. 2019; 35(5): 318–322.

v Indian Journal of Ophthalmology. 2021 Sept; 69(9): 2304–2309.

Jonathan D Solomon MD is an anterior segment surgeon and medical director at Solomon Eye Physicians and Surgeons in Bowie and Greenbelt, Maryland, USA.

Caroline Watson MD is an advanced anterior segment fellow at The Eye Institute of West Florida, Clearwater, Florida,

Nicole R Fram MD is an anterior segment ophthalmologist with Advanced Vision Care in Los Angeles, California, USA, a clinical instructor of ophthalmology at the Stein Eye Institute, University of California, Los Angeles, and a consultation section editor for the Journal of Cataract and Refractive Surgery.


“I’ll never use a regular microscope with oculars again”

Caroline Watson MD has seen the future of anterior segment surgery, and it is in 3D.

Now finishing an anterior segment surgery fellowship with Robert J Weinstock MD, a pioneer in 3D headsup surgery, Dr Watson has extensive experience using 3D heads-up devices for all her procedures since her fourth year in residency. These include the Alcon Ngenuity, the Zeiss Artevo, and the BVI Beyeonics One 3D systems throughout her fellowship year. To date, she has performed more than 1,000 procedures using 3D heads-up technology.

Her preference? “At the moment I don’t have a preference. All the 3D systems are far superior to a conventional operating microscope with oculars. All these devices allow the surgeon to break free from the microscope and deliver a better view in a more comfortable operating position. My goal is to help other surgeons understand what a tremendous benefit this technology is to both the patient and the surgeon.”

Dr Watson sees the broader and deeper view offered by 3D operating technology as a patient benefit. “The depth of focus and immersive view definitely makes me a safer surgeon. With a 3D system, you get a very large image in perfect detail. You can see everything from the anterior corneal plane to the posterior lens capsule, so you are able to anticipate what is happening more quickly and avoid mistakes. There is no longer the need to look away from the surgical field as instruments are passed and then readjust to looking through the oculars.”

By allowing more ergonomic body positioning, 3D systems can help avoid back and neck injuries, potentially improving productivity and extending surgical careers, Dr Watson said. “Surgeons tend to think they are invincible, but many suffer from chronic neck and back pain that limits their ability to perform more surgery in a day. Many surgeons have had to end their careers early due to occupational health issues. Heads-up surgery will help prevent this.”

Adjusting to 3D does take some effort, she said. “It takes about 20 cases, not just three or four. Additionally, proper OR setup is crucial for success with this technology.”

As 3D technology continues to advance and integrate more data and capabilities such as intraoperative OCT, younger surgeons will need to make the transition to keep up,” Dr Watson predicted. “Why would you drive a 1950s car around when what you want is a Tesla? I’ll never use a regular microscope with oculars again.”

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