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Core competencies in ophthalmology

Video recording in ophthalmic surgery

Brandon C. Thia, MBBSa,*, Nathan J. Wong, MBBS, FRANZCOb,

Shivanand J. Sheth, MBBS, MS, FRANZCOc
a
Austin Hospital, Melbourne, Australia
b
Bristol Eye Hospital, Bristol, UK
c
The Royal Victorian Eye and Ear Hospital, Melbourne, Australia

article info abstract

Article history: Video recording in ophthalmic surgery has immense potential to drive quality
Received 11 November 2018 improvement in patient care, ophthalmology training, and research. Not only do surgical
Received in revised form 18 January videos permit introspective and critical analyses of surgical technique, they also allow for
2019 objective assessment, allow for more informative audits, and are an invaluable medium for
Accepted 18 January 2019 surgical education. Unfortunately, medical-grade video recording equipment is often
Available online 28 January 2019 costly. Various novel methods of video recording that utilize commercially available
Edward Raab and Andrew G. Lee, products offer adequate alternatives. Certain ethical and legal issues also need to be
Editors considered before the commencement of video recording in the operating room to protect
both the patient and surgeon. We review the current applications and methods of video
Keywords: recording in ophthalmic surgery described in the literature, as well as the potential ethical
video recording and legal issues surrounding video recording.
ophthalmic surgery ª 2019 Elsevier Inc. All rights reserved.
self-assessment
assessment
quality improvement
documentation
education
methods of video recording

Video recording in ophthalmic surgery dates all the way and methods of video recording in ophthalmic surgery
back to the early 1950s with Sir Nicholas Harold Ridley, the described in the literature, as well as discuss the potential
inventor of the intraocular lens and pioneer of intraocular lens ethical and legal issues surrounding video recording.
implantation, also being the first ophthalmologist to televise
and film ophthalmic procedures.10,44 Since then, video
recording of ophthalmic surgery has become increasingly 1. Applications and benefits of video
common around the world. The potential benefits of video recording in ophthalmic surgery
recording are manifold, ranging from improvement in the
quality of patient care to educational and research purposes26; 1.1. Self-assessment and evaluation
however, the optimal setup for video recording remains
uncertain and can vary based on the equipment available at As surgical trainees experience increasingly limited
respective institutions. We review the current applications opportunities to perform procedures owing to various factors

* Corresponding author: Brandon C. Thia, MBBS, 145 Studley Rd, Heidelberg, Vic 3084, Australia. Tel.: þ61 03 9496 5000; Fax: þ61 03 9458 4779.
E-mail address: [email protected] (B.C. Thia).
0039-6257/$ e see front matter ª 2019 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.survophthal.2019.01.005
 s u r v e y o f o p h t h a l m o l o g y 6 4 ( 2 0 1 9 ) 5 7 0 e5 7 8 571

such as duty hour limitations and productivity, quality, and improvement in the field of competitive sport that is
safety pressures, the utility of employing a self-reflective becoming increasingly utilized in various surgical specialties.
approach toward procedures that they do perform is This approach is intended to complement the traditional
becoming more recognized.14,17 Using video recordings for method of intraoperative guidance and feedback to maximize
self-assessment encourages the surgeon to analyze critically the learning potential from cases. Given that most ophthalmic
and reflect on intraoperative performance and decision procedures are performed under local anesthesia, this is
making, thereby augmenting the educational value of each especially important as both trainee and supervisor may
case.43 Mistakes, near misses, or periods of failure to progress refrain from certain conversations intraoperatively, thereby
that occur during the procedure can also be easily revisited possibly foregoing valuable teaching points. In addition,
and ways to prevent these from reoccurring in subsequent video-based coaching has been shown to allow supervising
surgeries deliberated upon.1 surgeons to make more teaching points per unit time, address
Video recordings can also be used for more objective more complex topics such as intraoperative decision making
self-assessment of surgical skill and technique. Several and failure to progress, and provide more individualized
assessment tools that aim to provide more standardized feedback as compared to intraoperative teaching.19
assessment of surgical skill in ophthalmic surgery have been No studies investigating the effectiveness of video-based
developed and validated and can be used to assist in coaching in ophthalmic surgery were found during the
self-assessment. Although these assessment tools were literature search; however, such studies have been published
originally designed for intraoperative use, they can be easily in other surgical specialties including general surgery, and
adapted or modified for video-based use.11,47 Examples include obstetrics and gynecology.3,35 One such study by Bonrath and
the Objective Assessment of Skills in Intraocular Surgery coworkers was a randomized controlled trial that studied the
(OASIS),7 Global Rating Assessment of Skills in Intraocular effect of video-based coaching on the performance of surgical
Surgery (GRASIS),8 Objective Structured Assessment of Cata- trainees in a laparoscopic procedure. The group that was
ract Surgical Skill (OSACSS),36 and the International Council of randomized to receive coaching scored significantly higher on
Ophthalmology’s Ophthalmology Surgical Competency a standardized procedure-specific skill scale and made
Assessment Rubrics (ICO-OSCAR).15 These assessment tools significantly fewer technical errors at the end of their surgical
provide an alternative to traditionally assessed measures such rotations.3
as surgical times, patient outcomes, and complication rates Video-based coaching is not only for trainees. After gaining
that, although important, may not accurately reflect the their qualifications, ophthalmic surgeons often operate
intraoperative performance of the surgeon. In addition, each independently and rarely have the opportunity to receive
step of the procedure is scored individually, thus helping the performance feedback, which may result in complacency or
surgeon identify specific areas for improvement. stagnation of surgical skill. Studies have shown that
Although constant self-assessment should be encouraged video-based coaching is beneficial and well received even
for ophthalmologists of all skill levels, caution should be among practicing surgeons.20,42 As such, research into the
exercised to prevent its overemphasis during the early years effectiveness of video-based coaching in ophthalmic surgery
of training. A study published by Casswell and coworkers will be of particular interest to both training and practicing
investigated whether ophthalmology trainees of varying ophthalmologists.
seniority were able to assess accurately their own competence
in cataract surgery by comparing the OSACSS scores they gave 1.3. Video-based assessment
themselves with scores given by expert assessors after review
of surgical videos.5 This study showed that proficiency in Video-based assessment has potential roles in various areas
self-assessment of surgical skill improved with seniority and of ophthalmic surgery. It can be used for formal assessment of
experience. As such, self-assessment may not be as effective ophthalmology trainees, assessment of ophthalmologists in
for junior trainees who are not yet able to recognize their own distant locations where onsite assessment is impractical,
mistakes or inefficiencies. training and certification of skill in new procedures, and for
Interestingly, a study by Pittner and coworkers showed revalidation of surgical skills.
that conducting frame-of-reference training sessions for the The main benefit of video-based assessment over
grading of cataract surgery videos significantly increased the in-person assessment is the minimization of assessor bias,
ability and confidence of ophthalmology trainees to rate video especially if video recordings are processed and anonymized
recordings, with the greatest effect seen in the most junior beforehand.41 If a validated assessment tool is used in
group of trainees.32 conjunction, video-based assessment provides a reliable,
Although self-assessment of video recordings is becoming standardized, and objective way of assessing surgical skill.
common practice among ophthalmic surgeons, the evidence A study conducted by Wang and coworkers demonstrated
for it is sparse. Further research into the effectiveness of the utility of video-based assessment in the teaching of
constant, accurate self-assessment is needed. manual small incision cataract surgery in rural China.47 After
52 trainees underwent comprehensive training in manual
1.2. Video-based coaching small incision cataract surgery and were deemed
competent to perform the procedure independently, a single
The practice of reviewing video recordings with an expert who case was recorded at random for each trainee to be assessed
then provides immediate feedback and advice, also known as by two expert reviewers using a modified version of the
video-based coaching, is a common method of performance ICO-OSCAR for manual small incision cataract surgery
572 s u r v e y o f o p h t h a l m o l o g y 6 4 ( 2 0 1 9 ) 5 7 0 e5 7 8

(ICO-OSCAR:SICS). Results showed good interrater reliability recording any complications that may have occurred.
for all but one surgical step (capsulotomy), thus Although it is easy to audit variables such as surgical times,
demonstrating the good reproducibility of this method of complications, and patient outcomes using these records,
assessment. The video recordings also allowed the reviewers they are largely unhelpful when trying to determine the root
to identify steps that were poorly performed, namely draping cause behind particular outcomes and, conversely, final
of the surgical field, hydrodissection, and wound closure. This outcomes may not accurately reflect the quality of the surgery
subsequently prompted the authors to emphasize the itself. Written surgical records also rarely account for
importance of these steps in updated training materials. important near-miss events. Hence, it has been proposed that
Limitations of video-based assessment include the implementing an institution-based policy of routinely
inability to assess actions outside of the operating field and recording videos of procedures and archiving them for the
other nontechnical skills such as communication and purpose of documentation and audit will lead to more
teamwork. There is also the potential for dishonesty with the opportunities for quality improvement.13
submission of unoriginal or tampered videos. An example of video recording being used for quality
improvement is seen in the retrospective study by Malhotra
1.4. Motion analysis and coworkers that aimed to identify reasons for poor surgical
outcomes following endoscopic dacryocystorhinostomy.27
Motion analysis is another emerging method of assessing The authors performed an audit on 38 consecutive
surgical technique. Instead of grading the surgeon’s endoscopic dacryocystorhinostomy procedures performed by
competency in performing procedures, motion analysis three oculoplastic trainees and identified cases that failed or
provides a quantitative and objective measure of the required revision surgery. Video analysis of these cases
surgeon’s dexterity by measuring metrics such as number of allowed the reviewers to identify the probable reasons for
movements, path length, and time taken. Motion analysis is failure, such as inadequate superior bony rhinostomy,
usually performed using a physical instrument such as the incomplete retroplacement of posterior nasal mucosal flaps,
Imperial College Surgical Assessment Device, which requires and significant bleeding. Similarly, a study by Chang and
the placement of electromagnetic trackers on the surgeon’s coworkers retrospectively reviewed surgical videos to identify
hands or fingers.37,41 As a result, the whole process is the causes of radial anterior capsule tears that occurred
cumbersome and can only be carried out on a simulator or in a during femtosecond-assisted cataract surgeries.6
wet laboratory environment because of issues with sterility. These studies emphasize the utility of routine video
A novel technique of motion analysis that involves the use recording in identifying reasons behind poor surgical out-
of a computer visionebased tool to analyze video recordings comes, something that would almost certainly not have been
of cataract surgery (“PhacoTracking”) was described by Smith possible with conventional surgical notes. Moreover, as poor
and coworkers in 2013.40 By tracking the instruments captured outcomes and complications may not become apparent until
in the video recordings using computer software, the path days or even weeks after the procedure, systematic recording
length, number of movements, and time taken could be of every procedure performed ensures that it is always
quantified. PhacoTracking was shown to have a good possible to revisit any case.
construct validity by being able to discriminate surgeons of Newer technology has made it possible to capture aspects
different skill levels. of ophthalmic surgery that would otherwise be indiscernible
The ability of PhacoTracking to discern surgeon skill was to the human eye. Ogawa and coworkers described their
then compared with the already validated OSACSS experience with the Surgical Media Center (Abbott Medical
assessment tool by Din and coworkers.9 Metrics measured by Optics Inc., Santa Ana, CA), which is able to record the
PhacoTracking were found to have strong levels of correlation real-time phaco power, vacuum level, and aspiration rate
with OSACSS scores given by blinded assessors, thus during cataract surgeries and subsequently display these data
suggesting that motion analysis may potentially be used as a in graphs superimposed onto the surgical video.30 Recording
surrogate marker of surgical skill. In addition, one of the global these parameters allowed not only the identification of
indices on the OSACSS assessment tooldEye Positioned inappropriate phacoemulsification technique but also the
Centrally Within Microscope Viewdwas able to be objectively cause of certain intraoperative complications to be identified.
quantified by measuring the average pupil path length and Documenting ophthalmic surgeries with video recording
pupil center from frame center distance throughout the case. has potential medicolegal implications that may concern
As PhacoTracking is currently a purely quantitative system surgeons and institutions. This is further discussed in the
and does not take into account human factors such as medical litigation section under ethical and legal
intraoperative decision making, it is unlikely to replace considerations.
human-based assessment. Instead, motion analysis can
provide surgeons with complementary data regarding 1.6. Ophthalmology education
instrument handling and efficiency.
Videos are an invaluable tool for surgical education at all
1.5. Documentation, audit, and quality improvement stages of training. A small study conducted by Malik and
coworkers demonstrated the effectiveness and acceptability
The conventional method of documenting surgical of a cataract surgery teaching video among medical students
procedures involves providing a concise summary of the in London.28 Most participants showed a significant
surgical steps performed during the procedure, as well as improvement in knowledge after watching the video and
 s u r v e y o f o p h t h a l m o l o g y 6 4 ( 2 0 1 9 ) 5 7 0 e5 7 8 573

many were agreeable to the use of such videos in be difficult with the small surgical field of ophthalmic surgery.
ophthalmology education. Various novel methods that use commercially available
During ophthalmology training, video atlases can be used cameras to make the recording of nonmicroscopic procedures
by trainees to study proper surgical technique outside of practical and affordable have been described in the literature.
the operating room. Videos capturing intraoperative These cameras can be mounted overhead or on the surgeon’s
complications can also be reviewed in preparation for similar head to provide a good view of the procedure.
situations in real life. Techniques that aim to increase the educational value
For the practicing ophthalmologist, videos are useful for of videos are also the subject of study and examples
teaching and learning new surgical techniques. New include stereoscopic video recording and hand movement
techniques described in the literature are now invariably recording.
supplemented with online links to video recordings, thus
decreasing the need for ophthalmologists to personally visit 2.1. Video recording of microscopic ophthalmic surgery
other centers to undergo training. Similarly, speakers at
ophthalmological conferences frequently make use of their Many modern surgical microscopes come with, or have the
own surgical videos to better explain and demonstrate option of, an integrated digital camera. Certain newer surgical
surgical techniques. As such, video recording allows for microscopes such as the Zeiss OPMI Lumera 700 (Carl Zeiss
quicker dissemination of new and innovative techniques, and AG, Oberkochen, Germany) and the Leica Proveo 8 (Leica
therefore more rapid advancements in the field of ophthalmic Camera AG, Wetzlar, Germany) also have built-in video
surgery. recorders.
Social media platforms (e.g., Instagram, Facebook) and Surgical microscopes that have an integrated camera, but
video-sharing web sites (e.g., YouTube) are also becoming not a built-in video recorder, require an external video capture
increasingly used for the informal dissemination of device to facilitate video recording. Video capture devices
educational content. Depending on limitations in file size and convert the video output from the microscope’s camera into
video length, sometimes only short clips of the key steps in digital video files that are then stored in a connected USB mass
procedures are uploaded. storage device. Pass-through video output from the video
capture device allows real-time video to still be displayed on
1.7. Improving surgeon performance operating room monitors. Companies such as Zeiss, Sony, and
TEAC offer medical-grade video capture devices for this
The improvement in performance of medical professionals purpose. These devices have the additional capability to be
brought about by video recording is a phenomenon that has connected to the hospital network and can streamline the
been documented in the literature.26 For example, a study workflow immensely if videos are being recorded routinely for
examining the impact of video recording on the quality of documentation. However, as these products can be costly and
colonoscopy performance showed that the quality of mucosal generally lack portability, they may not be a viable option for
inspection increased significantly when colonoscopists were some institutions or for ophthalmologists who are recording
made aware that they were being recorded.34 The perceived for personal archives. This has led to the increasing use of
increase in accountability of one’s actions during the commercially available video capture devices to record
procedure, and the Hawthorne effect (which is the change in surgical videos.1 These devices are favored as they are able to
behavior observed when people are made to feel important) capture high-quality videos, are compact, and are widely
are two plausible explanations for this phenomenon. available at relatively low cost.
No studies examining the impact of routine video If the surgical microscope does not have an integrated
recording on surgeon performance in ophthalmic surgery camera, then an external camera is required to facilitate video
were found during the literature search. recording. Most surgical microscopes are designed with, or
allow the addition of, a beam splitter that enables an external
camera to be attached directly to the microscope via a
2. Methods of video recording in the mechanical interface, most commonly a C-mount. Examples
operating room of medical-grade external cameras designed specifically for
this purpose include the Zeiss TRIO 610 HD Camera System
The use of a surgical microscope in many ophthalmic and the Leica HD C100 Medical Camera. Consumer-grade
procedures means that video recording can be as simple as cameras can also be easily attached to the beam splitter via
plugging in a USB mass storage device and pressing the record camera adaptors to facilitate video recording.21,46
button. Endoscopic procedures such as endoscopic In the absence of a beam splitter, another option would be
dacryocystorhinostomy are even easier to record given the to record videos through the assistant’s eyepiece. Sinha and
inherent use of a digital camera. coworkers described their experience with the use of a
On the other hand, oculoplastic, orbital, and strabismus consumer-grade camera held up to the assistant’s eyepiece by
procedures do not typically involve the use of a surgical another staff member to record cataract surgery.39 Although
microscope and have proved more challenging to film. they managed to satisfactorily film a video, this method is
Operating room camera systems are expensive, thereby rather inconvenient. Eyepiece adaptors that allow for stable
limiting their usage. Techniques that have been previously attachment of cameras to the eyepiece can be purchased
employed include over-the-shoulder video recording and online or made with 3D printing12 and will simplify the
tripod-mounted cameras, but obtaining an adequate view can recording process immensely.
574 s u r v e y o f o p h t h a l m o l o g y 6 4 ( 2 0 1 9 ) 5 7 0 e5 7 8

2.2. Overhead-mounted cameras for nonmicroscopic editing required to produce good-quality surgical videos.
ophthalmic surgery Unlike overhead mounted cameras, there is inherently a lot
more camera movement with POV video recording
Mounting a camera on an overhead object such as a surgical techniques. This was noted by Ho and coworkers during the
lamp or video monitor can provide a fixed, unobstructed, editing process with the number of vertical and horizontal
top-down view of surgeries and is well suited for the small alignment adjustments that were needed to center the frame
surgical field of ophthalmic procedures. Alternatively, if a during certain parts of the procedure.18 Parts of the video that
surgical microscope with video-recording capability is record events outside of the surgical field, for example, when
accessible, it can be positioned at a distance above the the surgeon looks around the room, also require editing to
surgical field to be used simultaneously as a light source and ensure anonymity of both the patient and staff. Finally, digital
camera. zooming was invariably required to enhance visualization of
An example of an overhead-mounted camera setup was the procedures because of the GoPro camera’s wide field of
described by Lin who used a modified GoPro Hero 4 camera view.4,18,29,49
(GoPro Inc., San Mateo, CA) to record videos of an enucleation The Google Glass (Google LLC, Mountain View, CA) is a
surgery and a ptosis repair.24 The GoPro series of cameras are relatively new piece of wearable technology that has also been
compact, commercially available cameras that are primarily employed to record POV surgical videos. It is an optical
designed for capturing high-definition action sport videos. head-mounted display with a built-in camera that is designed
As GoPro cameras have a wide field of view in their standard to be worn like a pair of spectacles. Rahimy and Garg described
form, they may capture unwanted footage of the their experience with using the Google Glass to record a scleral
surroundings, especially if placed at a distance from the buckle procedure.33 They found that the Google Glass offered
surgical field. In this report, the GoPro camera was refitted more independence to the surgeon with regards to
with a custom lens for greater magnification and a narrower intraoperative use due to features such as being able to tilt the
field of view, allowing the camera to be placed further away wearer’s head back to turn on the Google Glass and to
from the surgical field while still providing high-quality commence video recording by voice command. In addition,
video recordings. The camera was then mounted onto an the monitor that is situated just above the surgeon’s field of
overhead surgical light (using either a GoPro suction cup view allows the surgeon to monitor the video recording with a
mount or a GoPro Jaws: Flex Clamp) and connected to a quick glance up. The Google Glass is also much lighter than
computer monitor via an HDMI cable to ensure that the video the GoPro camera, which makes it advantageous in terms of
being captured was adequately focused. The videos obtained surgeon comfort.
from this particular setup were of high quality, and Nevertheless, there were certain problems encountered
anonymity was maintained with the narrow field of view. with the Google Glass. For example, the brightness of the
Maamari and coworkers described a similar method that overhead surgical lamps occasionally resulted in
used a modified GoPro Hero 3 þ camera mounted on an overexposure of the recorded video. This was less of a problem
overhead monitor.25 with GoPro cameras as the built-in automatic white balance
setting reduced the need for exposure and contrast tunings.18
2.3. Point-of-view video recording Like the GoPro camera, the wide-angle lens and lack of zoom
function in the Google Glass makes postproduction editing
Point-of-view (POV) video recording provides a view from the necessary. The short battery life also limits the length of video
surgeon’s perspective, which is arguably more intuitive for recording, although there are separate battery packs available
audiences. Several studies have had success with the that can be used to extend this. The highest video resolution
recording of POV videos using head-mounted cameras and possible with the Google Glass is also much lower than that of
novel wearable technologies such as the Google Glass. GoPro cameras, thereby limiting the quality of the footage
Use of a head-mounted camera for POV video recording in obtained. These sentiments were largely echoed in a study by
ophthalmic surgery was first described in the literature by Paro and coworkers, which compared the Google Glass
Warrian and coworkers.49 A GoPro Hero 3 þ camera mounted head-to-head with GoPro cameras for video-based
on a head strap was used to record multiple scleral buckle self-assessment of plastic surgery procedures.31 In 2017, a
procedures. They concluded that the videos captured using newer version of the Glass was introduceddthe Glass
this system adequately recorded the surgical field and the fine Enterprise Edition. This version boasts a longer battery life,
movements of the instrument tips. Ho and coworkers boasts a better camera, and can be customized to suit the
described a similar method of POV video recording using the operator’s needs. It will be interesting to see whether this
newer GoPro Hero 4 camera.18 One significant improvement improves the viability of the Glass for ophthalmic surgery
made in this study was connecting the camera to an iPad video recording.
(Apple Inc., Cupertino, CA, USA) via Bluetooth using the GoPro Procedures that require the use of surgical loupes are less
App, which enabled real-time viewing. The camera and suited to be filmed using the aforementioned techniques.
mount could then be adjusted at the start of surgery by the First, loupes are not able to be worn with wearable
surgeon (wearing a sterile plastic bag) or by a nonsterile technologies like the Google Glass unless prior modifications
operating room staff member to ensure proper centering of are made.31,33 The surgeon’s magnified intraoperative view
the video before recording. will also be very different to what is recorded.33 Specialized
The biggest barrier to POV video recording with head- cameras that are designed to be mounted onto loupes produce
mounted cameras currently is the amount of postproduction high-quality magnified videos but can be pricey.
 s u r v e y o f o p h t h a l m o l o g y 6 4 ( 2 0 1 9 ) 5 7 0 e5 7 8 575

2.4. Stereoscopic video recording surgical procedures. Hence, supplementing conventional

video recordings of the surgical field with video recordings of
Stereoscopic video recording is another method of video the surgeon’s hands has potential applications, particularly in
recording that has been described in the literature. the areas of education and assessment.
Three-dimensional (3D) videos provide a much more Ophthalmology trainees can use such videos to aid
immersive and realistic experience for the viewer as mastery of intraoperative hand positioning and instrument
compared to conventional two-dimensional (2D) videos. handling. Video recordings of the trainee’s hands during
Furthermore, as the perception of depth is undoubtedly surgery can also be obtained for the purpose of video-based
important in ophthalmic surgery, stereoscopic video coaching or formal assessment, which is especially useful
recording has the potential to increase the educational value for microscopic procedures because surgical supervisors may
of surgical videos. Typically, two cameras that are offset not be able to observe and correct trainees intraoperatively. In
slightly record two separate videos which are then viewed addition, video recordings of hands and instruments are
simultaneously using a stereoscope or virtual reality headset. useful for teaching more technically challenging procedures
Alternatively, specialized 3D surgical cameras such as those such as bimanual procedures and iridocorneal angle
used for heads-up surgery can also be used for video procedures.16
recording, with 3D glasses subsequently used for viewing. In 2014, Gooi and coworkers described a method of
Birnbaum and coworkers described a method of recording hand positioning during microscopic ophthalmic
stereoscopic POV video recording using two GoPro cameras surgery using a GoPro Hero 3 camera mounted onto the
fixed onto a 3D printed plastic mount worn on the surgeon’s surgical microscope, just beneath the surgeon’s eyepiece.16
head to record a scleral buckle procedure.2 The videos were The resulting video recordings from this setup satisfactorily
then merged together side-by-side using the GoPro Studio captured both hands of the surgeon. The positioning of the
software and viewed using a stereo viewer (Screen-Vu; Bere- camera also resulted in an intuitive view very similar to the
zin Stereo Photography Products). Potential limitations of this surgeon’s own perspective. Videos recorded from the
setup include the increased weight and its effect on surgeon microscope were then synchronized and superimposed onto
comfort given the need for two cameras, and the wide field of the videos from the GoPro camera to facilitate simultaneous
view of GoPro cameras that necessitates postproduction viewing. Kaneko and coworkers described a similar method of
editing. If 3D printing technology is unavailable, the GoPro 3D recording hand movements by mounting a Panasonic HX-A1
Hero system, which is a specialized 3D housing produced by camera (Panasonic Corporation, Kadoma, Osaka, Japan),
GoPro, Inc., can be used as an alternative.23 which is largely similar in functionality and specifications to
Stereoscopic video recording has also been attempted in the GoPro camera, onto the surgical microscope.22
microscopic ophthalmic surgery. Conventional video It may be more challenging to film good-quality videos of
recordings obtained from the surgical microscope are in 2D, hand movements when a surgical microscope is not in use. A
which is rather different from what the surgeon sees possible solution is noted in the study by Warrian and
intraoperatively. 3D medical cameras that utilize two cameras coworkers which used a head-mounted GoPro camera to
attached to either side of a beam splitter produce high-quality record POV videos.49 The authors found that the wide field of
3D videos, but have the downside of being costly. Gallagher view of the GoPro camera inadvertently captured the
and coworkers describe a novel method of stereoscopic video surgeon’s hands as well and with the use of editing software, a
recording by connecting two iPhone 4Ss (Apple Inc., Cuper- digitally magnified video of the surgical field could be created
tino, CA, USA) to the assistant’s left and right eyepieces using and superimposed onto the original video to show both
3D printed eyepiece adaptors.12 The videos from both iPhones aspects of the procedure.
were subsequently synchronized and combined using Warrian and coworkers also evaluated a combination of
video-editing software and viewed using an iPhone loaded head-mounted/chest-mounted POV recording system for
into a virtual reality headset. The resulting video quality was oculoplastic surgery.48 In addition to a head-mounted GoPro
described as excellent with good stereoscopic effect. camera, another GoPro camera was mounted onto a chest
As stereoscopic video recording of ophthalmic surgery is harness worn over the surgeon’s gown. Video footage from
still in its infancy, producing a single video can be tedious and the chest-mounted camera captured the surgeon’s hands and
time consuming. Videos have to be well synchronized to have a instruments well.
good stereoscopic effect during viewing, which may be a
problem for some setups such as the one described by
Gallagher and coworkers.12 GoPro cameras are advantageous in 3. Ethical and legal considerations
this aspect as they can be linked to a single remote control and
thus are able to be operated simultaneously with ease. Com- There are several ethical and legal issues that surround video
mercial 3D digital cameras may simplify stereoscopic video recording in ophthalmic surgery. A review article published in
recording in the operating room but currently remain untested. 2014 by Turnbull and Emsley provides a comprehensive
summary of these issues45; however, as laws and policies can
2.5. Video recording of hand positioning and instrument vary between countries and even institutions in the same
manipulation country, ophthalmic surgeons must ensure that they consult
and comply with local laws and policies at all times.
Proper hand positioning, instrument grip, and instrument Informed consent should always be sought before filming
manipulation are all key to performing safe and efficient of any procedure. Issues that should be discussed with the
576 s u r v e y o f o p h t h a l m o l o g y 6 4 ( 2 0 1 9 ) 5 7 0 e5 7 8

patient include patient confidentiality and anonymity, the 3.2. Purpose and intended audience of video recordings
purpose of video recording, ownership and storage of
video recordings, and potential implications with regards to Whether it will be used for education, formal assessment,
medical litigation. The ability to withdraw consent at any research, or routine documentation, the purpose of video
time should also be communicated to the patient, and recording should be clearly communicated to the patient
procedures to ensure deletion of all captured footage must be before the procedure as part of informed consent. The patient
in place. should also be aware of the intended audience of the video.
This may include other ophthalmologists, other medical
3.1. Anonymity and risk of patient identification professionals, medical students, or even the general public as
is the case for social media posts and posts on the personal
As with any form of visual media, maintaining patient web sites of surgeons. Videos that are recorded routinely, for
confidentiality in video recordings is of paramount example, as part of a surgeon’s personal archive for reflective
importance. Every precaution should be taken to ensure self-assessment or documentation, should only be used for
anonymity, especially if the video is to be shown to those not other purposes after the patient is reconsented.
directly involved in the patient’s care.
Videos recorded from the surgical microscope are 3.3. Ownership of video files
generally considered to be at low risk of patient identification
as the area that is filmed is small and limited to a single eye. Ownership of the video recording should be clarified as part of
Significant intraoperative patient or microscope movement is the consent process. Similar to a patient’s medical record, a
rare as well, reducing the possibility of other facial features video recording is generally considered to be the property of
being revealed accidentally. Ensuring that the video recording the institution in which it was created.45 Ownership is less
is started only at the beginning of the procedure after proper clear, however, when a surgeon is routinely recording his/her
centering and focus of the microscope and stopped own procedures for their personal archive. Regardless, some
immediately after wound closure is usually sufficient to patients may ask for a copy of the recording. This would
ensure patient anonymity. depend on local policies and should be made clear to the
Filming of nonmicroscopic procedures carries a higher risk patient during consent to prevent subsequent disagreements.
of patient identification. This can be minimized by ensuring
that the video only captures the area of interest as far as 3.4. Medical litigation
possible, either by adjusting the positioning of the camera,
narrowing the field of view, or increasing the magnification. The implications that video recordings may have in the face of
Most of the camera setups used in the studies mentioned medical litigation is a concern for some surgeons and
earlier allow real-time monitoring of the video feed, and institutions. In the event of complications, patients may seek
necessary adjustments can be made accordingly during the to use the video recording as evidence for negligence lawsuits
procedure. Use of opaque or translucent surgical drapes will and this would discourage surgeons from recording
also help to reduce the risk of patient identification by procedures in the first place. On the contrary, video recordings
obscuring facial features. should be considered the “gold standard” of documentation
Video recordings will ultimately require playback and given it records exactly what the surgeon saw and did. Thus,
postproduction editing to further curtail the risk of patient video documentation can and has actually assisted in the
identification. Unnecessary footage that is captured, for defense of malpractice claims.45 The original, unedited
example, when the surgeon looks around the operating theater recording should ideally be kept if it is to be used for
with a head-mounted camera, should be cut from the video. medicolegal defense.
Digital zooming simultaneously improves visualization of the An alternative would be to declare during the consenting
surgical field and reduces potential identifying features.4,18,49 If process that videos are recorded purely for quality improve-
needed, other techniques such as blurring can be used to ment purposes and thus would be nondiscoverable in the
ensure anonymity.38 The editing process requires the surgeon same way that mortality and morbidity meetings are not
to have some degree of proficiency with the use of editing discoverable.26 In other words, patients should be aware that
software and may be considered too complicated or laborious complications have already been made clear to them, and
by some. Patients should be informed if an external video recordings that inadvertently capture such
professional is to be employed in these circumstances. complications will only be used for quality improvement.
If audio is recorded during procedures, patient
confidentiality may be compromised through conversations 3.5. Storage and security of video files
between the surgeon, patient, and operating theater staff. It is
therefore sensible to avoid intraoperative audio recording In this day and age of increasing cybersecurity concerns,
altogether and add a verbal commentary postoperatively if storage and security of confidential digital data is of utmost
needed. importance. Secure systems should be in place at institutions
Another potential way that patient confidentiality may be to ensure safe storage of video recordings.
breached is through the inappropriate naming of video files If videos are stored in a portable hard drive, as is usually
with identifiable features such as the patient’s name or the case for personal archives, there is a possibility of lost or
medical record number. This is discussed further in the stolen data. It is therefore imperative that surgeons
section on storage and security of video files. implement additional measures to secure the data,
 s u r v e y o f o p h t h a l m o l o g y 6 4 ( 2 0 1 9 ) 5 7 0 e5 7 8 577

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