The present technology relates to an image processing device and a method, and an operating microscope system that enable an operation to be performed more comfortably.An image processing device includes: an image acquisition unit configured to acquire a coaxial illumination image obtained by performing coaxial illumination on an eye being an operation target, and an oblique illumination image obtained by performing oblique illumination on the eye； and an image processing unit configured to generate an operative field image of the eye on the basis of the coaxial illumination image and the oblique illumination image, or detect a specific region on the basis of at least either one of the coaxial illumination image or the oblique illumination image. The present technology may be applied to a microscope system.
