Enhanced Surgical Efficiency with 3D Heads-Up Visualization in Vitreoretinal Surgery: A Retrospective Comparative Study

Background/Objectives: This study analyzed intraoperative parameters, structural safety, and morphofunctional outcomes of vitreoretinal procedures performed using a conventional operating microscope versus a three-dimensional (3D) heads-up digital visualization system. Methods: A retrospective single-surgeon case series included 248 eyes undergoing pars plana vitrectomy for epiretinal membrane (ERM), macular hole (MH), or rhegmatogenous retinal detachment (RRD). Patients were divided into conventional microscope (n = 122) and 3D heads-up (n = 126) groups. Primary outcomes included surgical duration, endoillumination intensity, best-corrected visual acuity (BCVA), anatomical success, and complications over a 6-month follow-up. Results: The 3D cohort showed a significantly shorter global median surgical duration (50.0 vs. 60.0 min, p = 0.001). Multivariate regression confirmed the 3D system as an independent predictor of shorter operative time globally (p = 0.011). After adjusting for baseline disease severity imbalances in the ERM subgroup, the 3D system maintained an independent reduction in surgical duration of 5.5 min (p = 0.044). The 3D system also required significantly lower endoillumination across all procedures (p ≤ 0.002). Anatomical success rates were high and comparable across indications. Both groups achieved similar and significant visual improvement at 6 months (p = 0.120). Structural safety biomarkers (SANFL, DONFL) and complication rates remained comparable. Conclusions: The 3D heads-up visualization system demonstrated comparable functional and anatomical outcomes to conventional microscopy across standard vitreoretinal procedures. It allows for surgery under significantly lower light conditions and demonstrates the potential to optimize operative time, particularly in ERM peeling. Furthermore, it maintains an equivalent structural safety profile to conventional surgery.