STEUBENVILLE — When Amanda McGrail was diagnosed with Cushing’s disease, she knew that surgery would be needed.

What she didn’t know was that she would become the first participant in a clinical trial aimed at determining whether mixed reality technology can be safely used in an operating room.

“The journey to figure out what was wrong started in the middle of 2024,” McGrail, a Steubenville native who now lives in Baltimore, explained. “I had been gaining weight with no explanation, and the doctors couldn’t figure out what was wrong. It took the better part of a year to figure out what was wrong, but when they did, surgery was the next step.”

She said she had planned to have the operation done in Baltimore, but issues with her insurer led her to have to look into other options.

“I had originally intended to have the surgery at Johns Hopkins,” said McGrail, who is an engineer at Textron Systems in Hunt Valley, Md. “Johns Hopkins and my insurance company had some disagreements, and they had a falling out.

“So, I asked the surgeon at Johns Hopkins if he had any recommendations for other surgeons, and he said he had a friend at UPMC, and he recommended Dr. Georgios Zenonos.”

Deciding to have the surgery done in Pittsburgh, McGrail, the daughter of Deborah and James McGrail of Steubenville, said, was a great option because it would allow her to recuperate at home.

She said she didn’t know the work would be done by using an Apple Vision Pro headset until right before her scheduled operation.

“I did not find out about the study until the night before,” the Catholic Central High School graduate said. “Dr. Edward Andrews asked if I would be willing to participate, and I said, of course.”

Andrews is a UPMC neurosurgeon, assistant professor of neurosurgery at the University of Pittsburgh and founding executive co-director of the Surreality Lab, which developed the technology.

“This study represents an important step toward a future operating room where surgeons can access visual information more intuitively, reduce physical and cognitive strain and integrate multiple digital tools into a single, immersive workspace,” Andrews said.

According to the report on the study, use by the surgeon of the mixed reality headset, which had the feed from an endoscopic camera routed into it, showed no significant difference in key performance measures between the mixed reality view and a conventional 2-D display. Surgeons also reported reduced task load when using the mixed reality interface.

According to UPMC, the endoscopic skull base procedure often involves two surgeons working simultaneously through the nasal corridor. Both surgeons would typically look at ceiling-mounted monitors, which can disrupt sight lines and create ergonomic challenges.

“In these cases, even small barriers can make it harder for the entire team to work efficiently,” Zenonos said. “Mixed reality allows you to place the surgical view exactly where you want it, without shifting your posture or line of sight. You’re in control the whole time, all while your hands stay sterile.”

Zenonos, a UPMC neurosurgeon and associate professor of neurosurgery at Pitt, worked closely with Dr. Garret Choby, an otolaryngologist head and neck surgeon at UPMC, on several of the cadaver procedures.

“My first response was, absolutely, I would love to do that, that sounds awesome,” McGrail said. “That was followed by a little bit of trepidation. But, he confirmed that the old methods to the old monitors and the way they used to do it would be available should the mixed reality not work the way they had intended. I was like, if you have the old way of doing it, we might as well try the new way.”

Information from the monitors can be shown to the surgeon through the headset, and the doctor has the option of accessing as much or as little as is needed at any point in the procedure.

“In theory, by creating a digital sphere that the operating room functions through, you can really break some of the bounds of what the operating room is capable of,” Andrews explained. “You’re not limited by four walls and the spaces that pieces of equipment occupy any more. Suddenly, you have an infinite resource and can bring in as much data or as little data as you need to guide the surgeon. It’s quite fitting that this development is being paralleled right now by a movement in artificial intelligence called agentic AI.”

Agentic AI systems are designed to achieve specific goals by independently creating, executing and refining their own action plans

By digitizing the operating room, said Elizabeth Reid, the manager of media relations for UPMC and University of Pittsburgh Health Sciences, the hope is patients wouldn’t have to go to a Johns Hopkins or a UPMC to access care that might normally be available only in the largest medical centers. It would extend the ability for that work to be done at smaller hospitals.

“If you live in a rural area or you are in a smaller center, we’re building technologies that will enable service providers there to deliver care that’s comparable to a primary care center. So, your mom, your wife, your son or your uncle won’t need to be flown to Pittsburgh. You don’t need to drive five hours to Pittsburgh to receive that level of care,” Andrews explained.

Connections for the system are made through a local area network, which means there’s not a reliance on the operating room Wi-Fi. The team working on the project has been able to solve latency issues, Andrews added.

“There’s no such thing as no latency — it doesn’t exist. It’s a speed of light problem,” Andrews said.

McGrail, Andrews said, was considered to be a good candidate for the procedure because of where her tumor was located.

“She had a tumor in the right region,” he said. “The initial reason for selecting her, at least on scan, is that it looked like a relatively straightforward case. Now, in this area, straightforward seems a bit inaccurate because you are talking about a very, very small window that is surrounded by really critical things.

“So, a movement that’s half a centimeter to the left can injure one of the big vessels to the brain. But when we reframe it a bit, the area that the pituitary occupies is fairly well-protected, so we chose that case because we figured it would remain within that space, so it wouldn’t require a lot of dissection manipulation around the surrounding structures and also of the healthy pituitary.”

It turned out that Zenonos had to also take some tissue that exposed and involved him operating on the internal carotid artery, which was not expected. Despite that, everything went beautifully, Andrews explained.

Cushing’s disease stems from a noncancerous tumor on the pituitary gland which causes the adrenal glands to flood the body with excess levels of the stress hormone cortisol. McGrail said her recovery has been slow and steady and that she no longer feels constantly stressed.

She added that she was happy she had the chance to recover from the surgery at home.

“We went on a grand tour,” she said. “I hadn’t been home in a couple of years, so I got to see the latest expansion at the Franciscan University of Steubenville, and my mom took me to Capri for a sausage sandwich — and it was amazing. We went to Amish country, which is a favorite pastime of ours, and we visited some of our favorite restaurants.”

McGrail explained that being the first to have this type of surgery was a different experience.

“It was unreal,” she said. “To me, I didn’t get to participate, I was asleep the whole time. From my point of view, the experience would have been the same, regardless. Anything that makes the surgeon’s job better is great. It is a little bit weird knowing that I’m the first. I did see an article on UPMC’s website about it, and I was, like, oh, I’m that person. My sister said the same thing — she’s like, it was weird that you were the person. It’s weird but it feels good.”

Andrews said McGrail and the others who have now gone through the surgery have resilience.

“It takes a lot of courage to be the first, second, third, fourth, fifth, sixth or seventh person to go through something in the world,” he said. “But they willingly did it, and, thankfully, we delivered on our promise.”