Gaze Characteristics Using a Three-Dimensional Heads-Up Display During Cataract Surgery

Purpose: An observational study to investigate differences in gaze behaviors across varying expertise levels using a 3D heads-up display (HUD) integrated with eye-tracking was conducted. Methods: 25 ophthalmologists (PGY2-4, fellows, attendings; number(n) = 5/group) performed cataract surgery on a SimulEYE model using NGENUITY HUD. Results: Surgical proficiency increased with experience, with attendings achieving the highest scores (54.4 ± 0.89). Compared with attendings, PGY2s had longer fixation durations (p = 0.042), longer saccades (p < 0.0001), and fewer fixations on the HUD (p < 0.0001). Capsulorhexis diameter relative to capsule size increased with expertise, with fellows and attendings achieving significantly larger diameters than PGY2s (p < 0.0001). Experts maintained smaller tear angles, initiated tears closer to the main wound, and produced more circular morphologies. They rapidly alternated gaze between instruments and surrounding tissue, whereas novices (PGY2-4) fixated primarily on the instrument tip. Conclusions: Experts employ a feed-forward visual sampling strategy, allowing perception of instruments and surrounding tissue, minimizing inadvertent damage. Furthermore, attending surgeons maintain smaller tear angles and initiate tears proximally to forceps insertion, which may contribute to more controlled tears. Future integration of eye-tracking technology into surgical training could enhance visual-motor strategies in novices.