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Operating in a new dimension with 3D visualisation

A new era in ophthalmic surgery has dawned with the emergence of 3D visualisation systems. Surgeons discuss how Alcon’s latest advance in this field is offering new levels of comfort, efficiency and teaching advantages in Australian operating theatres.

With the rapid speed of diagnostic ocular imaging advancements during the past 20 years, ophthalmic surgeons would be forgiven for wondering why arguably their most important tool – the surgical microscope – hasn’t evolved at the same pace.

Dr Nathan Kerr.

Up until recently, the analogue microscope remained fundamentally unchanged for 50 years5. But its incumbency is now being challenged with the rise of digital 3D surgical visualisation systems now offering unprecedented intraoperative views.

Chief among these technologies is Alcon’s NGenuity 3D Visualisation System. It was first introduced to Australian surgeons in 2017 and has undergone another transformation with the NGenuity 1.4 software upgrade.

While the technology was first touted as a key tool for vitreoretinal surgeons, it’s now gaining popularity among anterior segment surgeons who are reporting superior visualisation, which is proving particularly useful in their most complex cases.

Dr Nathan Kerr is a leading Australian cataract and glaucoma surgeon and recently used the system during public lists at The Royal Victorian Eye and Ear Hospital (RVEEH).

In addition to the superior visualisation, he says NGenuity can overcome musculoskeletal issues that often trouble surgeons later in their careers. It also promotes greater cohesion between theatre staff4, but he believes its biggest impact will be as a teaching tool for the next generation of ophthalmic surgeons.

“You don’t want to go back to a normal microscope after you’ve used NGenuity,” Kerr, who practises privately at Eye Surgery Associates and is a principal investigator in glaucoma at the Centre for Eye Research Australia, says.

“For public teaching hospitals, it’s going to be revolutionary by enhancing the learning experience of surgical trainees. Being able to view immersive 3D images with edge-to-edge clarity on a high- definition screen in real time makes the system an ideal educational tool. Plus, the surgeon and trainee can easily swap positions during a case without having to adjust the microscope eye pieces.”

In the operating room, NGenuity changes the experience for the surgeon, assistant, observing medical students/registrars/fellows and ophthalmic nurses, in myriad ways.

Firstly, the surgeon performs surgery by sitting in a neutral spine position looking at a 3D surgical screen that can be moved to a position that suits the team, instead of leaning forward and looking down the conventional microscope eye pieces2,8.

Wearing polarised glasses, every person in the theatre can watch the surgery take place, viewing the same screen as the surgeon – a marked difference over traditional surgery where often only the surgeon and assistant can easily see what’s occurring, with support staff often watching on a small monitor.

Colour filters can customise the view and highlight ocular structures.

To achieve this, a 3D High Dynamic Range (HDR) camera is mounted to the microscope (regardless of the manufacturer), which then transmits to a high-speed processor before the live 3D image is projected from a 4K OLED surgical display1.

Kerr says it provides an unparalleled view with an extended depth of field, enhanced magnification, and better contrast even at low illumination.

“Cataract and complex anterior segment surgeries require excellent visualisation. Using the NGenuity system, every structure is in focus at once, from the cornea to the posterior capsule, improving depth perception and visualisation for delicate intraocular manipulations. This helps me deliver the best outcomes to my patients,” he says.

“Using a traditional analogue microscope, the centre of the view is clear but the image degrades towards the periphery. The NGenuity system provides a panoramic view with a clear image from one edge to the other. This is especially important in microinvasive glaucoma surgery (MIGS), so I think this system is a gamer-changer for viewing angle structures and MIGS.”

Kerr says it provides better depth perception than the human eye can achieve using an analogue microscope. Colour filters can customise the view and highlight ocular structures and tissue layers1.

“With glaucoma stents, placement needs to be exact for them to function optimally. Having a highly magnified view of Schlemm’s canal in perfect focus enhances the ease and certainty of stent insertion. With the digital image filters, you can highlight structures like Schlemm’s canal, making it easier to visualise compared to an analogue microscope.”

Kerr has also performed several cataract surgeries with the system. He’s found it offers much better visualisation, making it easier to perform delicate steps like polishing of the posterior capsule. Through Alcon’s Datafusion software, NGenuity connects with other systems to display key parameters – such as intraocular pressure, flow rates, and infusion pressure – on the main screen.

“It helps increase situational awareness, enhancing safety and efficiency,” he says. “By having a unified source of information on one screen, I can see all the information I need without ever taking my eye off the patient.”

During surgery, Kerr says the system’s highly sensitive camera enables surgery to be performed with low light illumination settings, which is safer for the retina and more comfortable for patients having surgery under topical anaesthesia.

“In the day-surgeries I operate, I’m already trying to convince them to adopt this technology so I can offer it to my private patients.”

Ergonomic surgery 

A common problem for ophthalmologists with traditional binocular microscopes is poor neck and back postures, leading to musculoskeletal fatigue and injuries. These have been associated with reduced surgical longevity, with the prevalence of symptoms reported to be as high as 62%6-8.

When performing MIGS, Kerr says the patient and the microscope needs to be tilted 35 degrees toward the surgeon, which leads to an awkward and uncomfortable position for the surgeon with a conventional microscope.

Dr Nathan Kerr performing surgery in a sitting, neutral spine position, and wearing 3D glasses.

“With NGenuity, because I don’t need to look down the microscope eye pieces I am able to sit upright in a comfortable position, even when the microscope is at an angle,” he says.

“Being able to look straight ahead reduces neck strain and provides a more natural position for your arms which helps reduce fatigue. The other benefit is how quickly you adjust to the system; the learning curve is minimal. Even on my first case I felt confident throughout the entire case.”

Operating room efficiency 

Ms Kylie-Rae Thomas is the nurse unit manager of operating theatres at Sydney Eye Hospital where NGenuity 1.4 was trialled for three months last year.

“Following the trial, I already have a number of surgeons coming to me asking when we’re going to get NGenuity back,” she says, noting, however, that some theatre staff and surgeons have occasionally felt nauseous while adjusting to the 3D display.

Through its advanced visualisation, she’s seen the system offer major benefits for theatre efficiency and training.

Surgeons can also record their work to be played back in high resolution 3D in a range of teaching environments, including conferences.

Traditionally, Thomas says nurses could only view the surgery on a small monitor, with many of the structures out of focus. They were often required to look out for cues from the surgeon or watch the monitor, but now they had become more engaged.

“This system allows you to see everything inside the eye with such precision, which gives you a greater understanding and appreciation. You can see the surgeon’s manoeuvring around the anatomy when they’re operating, whereas you wouldn’t see those fine motorskills and techniques usually,” she says.

“You’re watching exactly what the surgeon’s doing in real time, and therefore you can be more responsive to give them the instrument they need. This technology brings you where you need to be, focused on what’s happening, we’re all invested, and can see the surgical outcome and result for the patient which is very gratifying.”

A ‘revolutionary’ teaching tool 

Thomas’s Sydney Eye Hospital colleague, Dr Elisa Cornish, has also been impressed with the system’s ability to visualise structures during glaucoma surgery, particularly with the depth-of-field when conjunctival suturing during Baerveldt tube and trabeculectomy surgery. But she was most blown away by the magnification of the angle when inserting glaucoma stents.

Dr Elisa Cornish.

“I showed a video of it to the stent manufacturer to demonstrate how easy it is for teaching compared to looking through the assistant’s eye piece of the microscope, they were very impressed,” she says.

Cornish is a senior clinical lecturer at the University of Sydney, which involves supervising medical students, on eye term rotation, and registrars at Sydney Eye Hospital.

While the system broadcasts the surgery live – which has teaching benefits – surgeons can also record their work to be played back in high resolution 3D in a range of teaching environments, including conferences2.

“To demonstrate to junior ophthalmic trainees each step of the surgery with good visualisation has been the greatest benefit of all. I think the biggest selling point is its teaching capabilities, it would be an amazing educational tool for all types of ophthalmic surgery – teaching hospitals would be crazy not to utilise this technology,” she says.

“In addition, it offers personal insight into your own surgeries so you can assess where things go wrong – that learning capacity to refine your technique is amazing feedback for yourself and future surgeries.”

At RVEEH, Kerr notes public hospitals would be enticed by its capability to be mounted to most operating microscopes, regardless of the manufacturer, enabling hospitals to add new digital features to their existing hardware1.

“I also think private day surgeries will want to provide patients and surgeons with access to the latest technologies, such as NGenuity, to enhance patient care and the experience of their surgeons,” he says.

NOTE: Opinion based on healthcare professional impressions and experience after using NGenuity 1.4 Visualisation system in surgery. The healthcare professionals did not receive compensation. 


  1. NGENUITY® 3D Visualisation System Operator’s Manual
  2. Shoshany TN et al. The User Experience on a 3-Dimensional Heads-Up Display for Vitreoretinal Surgery Across All Members of the Health Care Team: A Survey of Medical Students, Residents, Fellows, Attending Surgeons, Nurses, and Anesthesiologists. Journal of VitreoRetinal Diseases. June 2020. doi:10.1177/2474126420929614
  3. Brooks CC., et al. Consolidation of Imaging Modalities Utilizing Digitally Assisted Visualization Systems: The Development of a Surgical Information Handling Cockpit Clinical Ophthalmology 2020:14 557–569  
  4. Eckardt C., Heads-Up Surgery for Vitreoretinal Procedures: An Experimental and Clinical Study 2016: 36:137 – 147
  5. Richard Keeler, The Evolution of the Ophthalmic Surgical Microscope, Hist Ophthal Intern 2015,1: 35-66
  6. Dhimitri KC, McGwin G Jr, McNeal SF, et al. Symptoms of musculoskeletal disorders in ophthalmologists. Am J Ophthalmol. 2005;139:179–81.
  7. Hyer JN, Lee RM, Chowdhury HR, et al. National survey of back & neck pain amongst consultant ophthalmologists in the United Kingdom. Int Ophthalmol. 2015;35:769–75.
  8. Honavar SG. Head up, heels down, posture perfect: ergonomics for an ophthalmologist. Indian J Ophthalmol. 2016;65:647–50
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