An introduction to digital and digitally assisted microscopes

Advances in optics are changing the landscape of ophthalmic surgery.

Technological advances in ophthalmic microscopes are changing the landscape of how ophthalmic surgery is performed. While several digital and digitally assisted microscopes with differing capabilities are on the market, they all have one major thing in common: advanced visual optics. They also allow for the integration of digital information and “heads-up surgery” where the surgeon, rather than using the oculars of the microscope, views the microscopic image on a display sent from a 3D camera.

Herein, I will provide an overview of the digital and digitally assisted microscopes on the market as well as how they benefit the surgeon, patient, and practice as a whole.

What’s on the market?

Here is an overview of what is currently on the market for ophthalmic surgeons.

The PROVEO 8 (Leica Microsystems) ophthalmic platform provides a complete visualization and workflow solution with digital imaging technologies. The surgeon benefits from better ergonomics and is able to display additional data on the HD 3D screen from third-party imaging devices. The microscope has preprogrammed settings for light, focus, and magnification, according to procedure and surgery phase, that can be changed with a tap of the footswitch. It offers FusionOptics technology, which combines high resolution and depth of field without refocusing.

The ZEISS ARTEVO 800 (Carl Zeiss Meditec) digital ophthalmic microscope provides a stereoscopic 3D image on a 55-inch, 4K monitor. It shows fine details and natural colors of the ocular anatomy, improved depth of field, and reduced light density. The surgeon can operate in a heads-up position while the OR team can see a real-time 3D view of the surgery. The microscope also automatically adjusts the settings based on the surgeon’s workflow. There are assistance functions for cataract surgery as well as settings for cornea, retina, and glaucoma surgery that can be viewed in the OR. One may also display real-time information, such as toric IOL position, biometry data, etc., on the monitor.

The NGENUITY 3D Visualization System (Alcon) includes a visualization software, DATAFUSION (Alcon), that integrates the microscope with the CENTURION and CONSTELLATION (Alcon) machines, technology platforms specific to cataract and retinal surgeries, respectively. It also now integrates with the intraoperative aberrometer ORA System with VerifEye+ Technology (Alcon). This system allows the surgeon to view, on the system’s 55-inch, 4K OLED display, 3D images (via a twin-sensor 3D, HDR camera), and parameters to monitor during surgery, including phaco settings, IOP, flow rates, laser power, and infusion pressure.


Most notably, the primary benefit of digital and digitally assisted microscopes with “heads-up” displays is improved optics, but the ability to sit comfortably throughout the day is a top priority as well. Traditionally, ophthalmologists have to hunch over patients and get very close to look through oculars to see what they are doing. When a surgeon performs many cases in a day, the cumulative effect can be damaging to the surgeon’s back and cervical spine. Over time, this approach takes a lot of wear and tear on our bodies. Studies show that between 30% and 50% of ophthalmic surgeons end up with cervical neck pain or, even worse, herniated discs due to the way we must position our bodies to view the eye with a traditional microscope.

The learning curve

The learning curve for digital and digitally assisted microscopes is short and not very steep. Certain microscopes are easier to adjust to than others, and surgeons may need to get accustomed to a slightly different angle in addition to viewing the image on the screen. Movements may be different and hand placement may be different. Most of us are used to resting our head against the microscope as we look through the oculars. That may seem like a silly thing, but when you no longer need to rest your head against the oculars of the microscope, it is a small change that may throw your body off slightly. However, I have found that one can adapt in as little as two or three cases.

Increase in efficiency

Transferring data to digital microscopes is efficient because biometry readings and toric lens alignments can be superimposed onto the screen and seen in real time without looking off to another screen, so the surgeon may not need to interrupt the procedure to view information.

The microscope is customizable to the surgery being performed. For example, I can overlay lens calculations, align a specific lens type, or have assistance with making an incision in the cornea—I can overlay lens calculations, align a specific lens type, or have assistance with making an incision in the cornea.

As surgeons adapt to this new technology and take advantage of some of its integration capabilities, such as the overlays and data transfer, there will be an increase in efficiency and a benefit to patient safety by going “markerless” and “paperless.”

Impact on staff

Anyone in the operating room—surgical assistants, technicians, medical students, residents—all have the opportunity to watch surgeries on a 3D monitor. This makes them better at their jobs because there are lots of ORs where the person scrubbing for the case doesn’t have the ability to look on a TV monitor; they are just passing things to the surgeon. The ability to see exactly what the surgeon is seeing is an incredible advantage for teamwork overall. Staff can better anticipate what is happening during the procedure, but it also serves as a tool for resident education, fellow education, and medical student education because everyone is seeing the same thing at the same time in 3D.

Added safety

In a COVID-19 world, digital microscopes offer an additional barrier of safety for surgeons and patients. Being able to look through 3D glasses, and not through the oculars, allows the surgeon to wear a full-face shield in the OR. There is a great safety advantage to having the ability to sit back and not hover directly over the patient’s face during surgery. The ability to cover my face and eyes with a face shield is an important layer of protection, for both patients and surgeons, amid the pandemic.

Another safety advantage is not having to handle paper charts. Many surgeons are still carrying their paper charts with their lens calculations to the OR. That can be an issue because a) the surgeon could lose those calculations and there could be a HIPAA violation and b) paper charts are more prone to human error.

Having data untouched by humans go straight from the measuring device to the OR is valuable. It increases efficiency and is better for patient safety. When a surgeon is trying to push a lot of patients through the OR, he or she will want to do it with as little room for error as possible. Digital and digitally assisted microscopes close that gap quite a bit.

Visualize the benefits

No matter the digital microscope that is being used, patient safety, staff education, efficiency, and ergonomics can see improvement. The visualization of digital and digitally assisted microscopes has changed how I approach ophthalmic surgery, because I am more comfortable and I’m seeing the eye in ways that I wasn’t able to visualize before. These scopes contribute to getting the best surgical outcomes because they remove a lot of variables from the equation. OP