• This study was initiated to investigate the hepatotoxic effects of wear particles from joint implants. • Our in vitro assays demonstrated that titanium (Ti) and cobalt-chromium (CoCrMo) particles significantly decreased cell viability in HepG2 cells, especially in ionic form. • Notably, Ti and Co ions were the most cytotoxic, causing marked nuclear integrity loss and increased apoptosis. • In vivo studies in mouse models demonstrated wear particles' systemic distribution and immunological impact. • These findings show the potential systemic risks associated with wear particles, especially concerning liver function. • Understanding the interactions between wear particles and liver cells is necessary to minimize potential systemic toxicity.

Purpose: To investigate differences in gaze behavior among vitreoretinal surgeons of varying experience levels during simulated pars plana vitrectomy with epiretinal membrane peeling using a 3-dimensional heads-up display (HUD) system with integrated eye-tracking. Methods: Twenty-six ophthalmologists—postgraduate year 4 residents (n = 10), vitreoretinal fellows (n = 9), and attending surgeons (n = 7)—performed simulated vitrectomy on model eyes using a 3-dimensional HUD system with eye-tracking. Gaze metrics (fixations, saccades, field awareness, HUD focus, and tear angle) and surgical performance (International Council of Ophthalmology, Ophthalmology Surgical Competency Assessment Rubric vitrectomy score) were evaluated. Statistical analysis included Pearson correlation, analysis of variance (ANOVA), and post hoc Tukey tests. Results: Surgical performance increased with experience (postgraduate year 4: 26.6 ± 1.3; attending: 42.5 ± 1.6; P < .0001). Attendings demonstrated fewer fixations (3454.0 ± 548.0 vs postgraduate year 4: 6114.0 ± 1349.0; P < .0001), shorter fixation durations (0.21 ± 0.015 seconds vs 0.277 ± 0.034 seconds; P < .05), and smaller saccade lengths (0.168° ± 0.082° vs 0.325° ± 0.094°; P < .01). They also showed greater HUD utilization (76.3% ± 7.3% vs postgraduate year 4: 45.0% ± 8.9%; P < .01), broader visual field awareness (51.3% ± 9.7% vs 17.3% ± 5.7%; P < .001), and more controlled membrane peel angles (7.1° ± 2.6° vs postgraduate year 4: 89.5° ± 22.6°). Novices primarily focused on instrument tips, whereas experts exhibited feed-forward gaze strategies with anchored fixation and situational awareness. Conclusions: Expert vitreoretinal surgeons demonstrate distinct visual strategies characterized by efficient gaze behavior, broad field awareness, and HUD-focused attention. These gaze patterns correlate with surgical proficiency and may serve as benchmarks for training. Eye-tracking integrated with HUD systems may enhance surgical education by allowing trainees to model expert gaze behavior and improve operative performance.

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.