New Mixed Reality Headset: First Exploratory Use in Intraocular Surgery and Telementoring

This article is published with digital features, including videos, to facilitate understanding of the article. To view digital features for this article, go to https://doi.org/10.6084/m9.figshare.28485428

The introduction of innovative visualization systems in intraocular surgery has allowed significant advancements in ophthalmology, leading to a shift from traditional to new surgical models. These systems have significantly enhanced visualization, precision, and surgical efficacy, setting novel standards for patient care. The traditional optical microscope is a reliable and widely used tool in ophthalmic surgery, however, it has limitations, including a fixed field of view and lack of integration with digital overlays, factors that may result in possible benefits for surgery [1‐3].

Three-dimensional (3D) technology and the use of innovative tools have allowed surgeons to interact with detailed anatomical reconstructions with significant advantages during complex procedures, due to the ability of superimposing virtual data onto a real-world view. Consistently, recent analyses have shown how head-up displays (HUDs) can enhance certain aspects of surgery, particularly in terms of ergonomics and keeping the surgeon informed—benefits that are especially valuable during long procedures [4‐6]. Nevertheless, those systems have downsides, including limited interactivity, static integration of imaging data, and a lack of real-time dynamic visualizations. Moreover, the technique’s evolution enhances the necessity of developing a unique, efficient innovative system of surgical training, which nowadays represents a flaw in surgical disciplines. In fact, different papers have outlined worldwide difficulties in surgical teaching among residents all over the world and across different specialties [7]. As a matter of fact, it is evident how the ophthalmology apprenticeship model, which relies on the presence of a surgical microscope, strongly limits the possibilities of teaching, resulting in the necessity of more flexible, innovative plans to maximize residents’ skill acquisition and create an inspiring, constructive learning environment [8].

Recently, global pandemic emergencies have significantly altered daily habits, accelerating the adoption of remote communication channels. As a result, telemedicine models have been introduced across various settings, demonstrating overall satisfaction, effectiveness, and safety [9].

The introduction of mixed reality (MR) technologies, combining augmented reality (AR) and virtual reality (VR) models, have brought to medicine the possibility of translating advancements in real-life surgical benefits that are able to assist surgeons in terms of efficacy and education [10].

In fact, the combination of AR and VR into a cohesive mixed reality platform provides the surgeon with immersive, interactive 3D visualization, and high efficiency in medical communication and technical education [11‐13].

However, the applicability of such a model in surgery has not completely been explored, despite recent papers reporting the efficacy of AR-based simulators in surgical training, with significant advantages in terms of learners’ progress and individual assessment [14].

A previous paper has explored applicability of a mixed reality headset (MRH) in oculoplastic surgery, underlining advantages in terms of improved visualization, enhanced precision, and communication among surgical teams [12]. However, to our knowledge, to date, no paper has yet explored the applicability of a MRH in intraocular surgery. Consistently, the impact of such a system in surgical training should be further investigated in order to allow the integration of surgical advancements and education, leading to parallel growth.

Therefore, the aim of this brief report is to first explore the unique applications of an MRH in intraocular ophthalmic surgery, focusing on its applicability in intraocular surgery and evaluating possibility of maximizing surgical teaching.

This pilot study included nine patients undergoing ophthalmic intraocular surgery between September and December of 2024. Three patients were scheduled for phacoemulsification and intraocular lens (IOL) implantation, three patients were scheduled for the removal of silicone oil (ROSO) (Video 1, online version of the manuscript, please note authors have the permission to publish the video from those whose faces appear) and three for pars plana vitrectomy (PPV) with epiretinal membrane (ERM) peeling (Video 2, online version of the manuscript, please note authors have the permission to publish the video from those whose faces appear).

All patients were enrolled among those being followed up at the Ophthalmology Clinic of University Gabriele d’Annunzio, Chieti-Pescara, Italy. Enrolled subjects were carefully informed about their condition, surgery, and video collection procedures. The study adhered to the principles outlined in the Declaration of Helsinki, and all patients provided written informed consent (Code AR2024). The authors confirm they have permission from those who appear in the videos to publish them. The exclusion criteria were: patients under 18 years old and those with ophthalmological conditions other than the one requiring surgery.

Intraocular surgeries are among the most commonly performed procedures worldwide. Specifically, recent reports have identified cataract surgery as the most frequently performed surgery globally [16]. Phacoemulsification and vitreoretinal surgery are highly precise procedures that are widely performed, necessitating continuous updates and innovations.

Moreover, these highly precise surgeries require extensive training and experience, with significant disparities observed worldwide across residency and fellowship programs [17, 18]. Recently, this has led to the widespread adoption of VR simulation training models, which have been shown to improve safety outcomes before real-life surgical experience [19]. Nevertheless, a recent review has highlighted the lack of proper consistent training program worldwide, advocating the development of ways to make it more consistent, maintaining patient safety as highest priority [20].

The traditional microscope is a significant limit in teaching and in transmitting the learner the OR workflow in a real-life setting. In this light, advancements in technology have allowed the development of novel techniques aimed at bringing novelty in surgical steps and education. Mixed reality is an innovative technology that combines AR and VR, offering an immersive, mixed experience that offers advantages in terms of visualization, precision, and education. Despite the application of AR and VR models in surgery across different specialties, to date, the role of these innovative technologies has mainly been limited to surgical training, showing overall efficacy and promising results.

In a recent review, the authors outlined the introduction of VR simulation-based systems in ophthalmology training as a revolutionary change in surgical training, despite the overall small worldwide distribution [21]. Today, the available systems, mainly designed for cataract surgery training, have shown overall encouraging results, with higher results when compared to wet-lab and dry-lab training methods according to recent reports [22, 23].

This highlights the need to improve surgical training among residents and fellows, a necessity further supported by several studies demonstrating disparities in trainee preparation for surgical practice. These findings advocate for the development of a new model of surgical training [24].

On the other hand, this is an expression of the necessity of translating advances in technology in medicine, leading to MR-integrated surgery.

We reported the applicability of a MRH in intraocular surgery by showing its effectiveness in concluding three different ophthalmic procedures efficiently and uneventfully. The integration of MRH in intraocular surgery positions it as a game-changer in complex surgical procedures. A key strength is its ability to incorporate multimodal imaging during surgery, provide real-time overlays of en-face slabs, and utilize 3D models to assist in precise surgical maneuvers, ultimately enhancing intraoperative decision-making [25‐27]. To our knowledge, this is the first study to analyze the application of an MRH in intraocular surgery. Previously, Orione et al. have tested the applicability of a MRH in eyelid malposition surgery. In their series, advantages in visualization, precision, and communication among surgical teams were noted, proposing the device as a valuable tool in ophthalmic surgery [12]. However, no data of application of MRH in intraocular surgery are present in the literature, leading to a void that needs further elucidation.

Differently, AR and VR have had a consistent influence on surgical education over the years, showing efficacy and future perspectives [28]. In fact, the use of AR and VR simulators has been rapidly expanding in ophthalmology, enabling training on virtual surgical simulators, which have been shown to enhance fellows' skills. In a recent review, Jiang and colleagues have demonstrated that VR simulators in ophthalmology education enhance learning, surgical training, and diagnostic skills [29]. Consistently, several papers have shown the efficacy of telementoring in the field of medicine, with concrete results in terms of diagnostics, management, and follow-up, alongside few works exploring the possibility of guiding surgery far from the OR primary operator location opening to interesting scenarios.

As a result, by integrating MRH into intraocular surgery and addressing the need for a surgical training program, our aim was to evaluate the effectiveness of a telementoring system based on MRH in intraocular surgery. This assessment considered surgical effectiveness, the availability of an all-in-one system, and the feasibility of a streamlined process without signal delay.

Our explorative analysis revealed a high level of satisfaction with the educational field. Residents, learners, and fellows were found to be more involved in the surgery, having the possibility of participating virtually, and even not having to be in the OR. Overall, for hygiene and sterility reasons, the number of OR personnel must be limited, preventing a large number of observers from being present during the procedure. As a result, this would allow the possibility of sharing surgery easily with a wide range of figures (e.g., students, medical staff, and trainees) not limiting the number of observers to the space of the OR. Moreover, the possibility of establishing direct contact with the environment outside the OR opens a wide range of applications relying on the FaceTime interface, and not only limited to surgeon–resident contact. In fact, by offering the possibility of screen mirroring, it enriches the surgery with both the utility and educational aspect, by giving the surgeon the possibility to give an immersive and complete experience to the observer being on the other side. However, it must be acknowledged that the mirroring function requires a shared Wi-Fi connection, thus calling for structural and functional adjustment and limiting its field of action on the same location, compared to the FaceTime functionality, which allows long-distance calls. Except for that, no other technical issues were encountered (e.g., device battery life, user interface, or integration of the MRH system with current existing OR technology in terms of compatibility, data synchronization, or system setup).

Nevertheless, its most applicable benefits would be in the development of a telementoring model of surgical training. In fact, the continuous all-in-one interface available upon surgeon request offers the surgeon the possibility of correlating the structural preoperative condition with the intraoperative steps, involving the scholars in the process, which precedes the surgical act itself. The effectiveness of surgery and the absence of signal delay makes it a safe teaching method, without influencing the surgical outcome, thus preserving patient safety.

In this light, the model would figure as a tutoring process, boosting fellow–surgeon communication during the procedure itself, despite distances. This would differ from conventional surgical teaching methods that require either the fellow observing the surgeon or the surgeon physically supervising the fellow in the OR. In this light, the proposed telementoring model would add one step in the two-step process, with a third phase where the surgeon may be requested by the fellow supervising the surgical procedure and discussing surgical steps with the possibility of implementing the number of requested consultants according to the type of surgery. In fact, its range of application finds its most potential in telementoring of young fellows in the OR setting making the fellow–tutor contact and communication easier. In fact, not only would it allow the tutor involvement upon request without issues in terms of signal delay or visualization but it would also include the possibility of involving more than one tutor based on the type of surgery, eventually requiring the consultation with more than one expert.

Without interfering with the surgical steps, this approach would enable the fellow to continue the procedure under supervision, facilitating tutor–learner interaction more effectively than current available calls, thanks to the all-in-one interface. Moreover, as previously mentioned, it would permit the contact even with far-based experts opening to a multi-layered model of knowledges transmission, which has no limits in expertise, making the tutor–fellow contact easier and available at a shorter telematic distance.

In this context, the multimodal all-in-one system not only enhances feasibility but also extends its effectiveness in medical education. It allows the surgeon to engage dynamically with residents, colleagues, or collaborators intraoperatively while in the OR setting. Moreover, it paves the way for a future scenario where the system could serve as the foundation for seamless communication between the fellow in the OR and the tutor, enabling real-time surgical guidance regardless of distance. This is supported by our findings, which demonstrated that communication was unaffected by time lag, despite the fellows observing the surgical case from different locations. This may open a new way of establishing knowledge transfer, connections, and continuous discussion, which is at the basis of consistent training, by developing a surgical telementoring model of training. However, there are several limitations in our study. First, a larger cohort of patients should be investigated, also extending the analysis to other type of surgeries (e.g., glaucoma surgery) and fully elucidating the absence of potential distractions or complications in a higher number of surgeries.

Secondly, we acknowledge that the use of subjective feedback to evaluate the overall response to the introduction of this innovative model may introduce bias. Moreover, to fully validate the telementoring model of surgical training, it should be tested by analyzing the scenario of its proper application.

In fact, despite the absence of technical issues other than the mirroring function requiring the same Wi-Fi connection, no other problems have been faced in our experience (e.g., device battery life, portability); however, we acknowledge that there may be certain limitations affecting the device’s widespread adoption in the OR that would require workflow adaptation. Besides, although the surgeon did not experience any cybersickness symptoms, longer surgeries may exacerbate adaptability difficulties. Moreover, future studies aimed at evaluating the applicability of this innovative model should extend the follow-up time to better detect post-operative complications. Additionally, integrating MR systems into existing surgical workflows requires specialized training, keeping a solid background knowledge and practical ability in traditional surgery a prerequisite in those accessing this system.

In conclusion, telemedicine has rapidly expanded across medical fields, yielding remarkable results in terms of satisfaction within clinical practice. As medicine continues to evolve, the development of new techniques should be considered as part of an innovative and supplementary educational approach to surgical training. In this context, the integration of MRH in intraocular surgery represents a game-changer in training the next generation of ophthalmic surgeons.