Safer procedures, less surgeon stress possible with robot-assisted cataract surgery

When we think of robotic eye surgery, we may mistakenly picture futuristic machines taking over while human ophthalmologists are left out.

Perhaps a better way of thinking about robotic ophthalmic surgery is to remember that it is robot assisted. These new machines will assist surgeons, not replace them, and will help us provide a higher level of precision and safety to our patients. Think of it this way: You are still the surgeon, but a better version of you with faster reaction times, a higher degree of accuracy, more efficiency and a lower risk for surgical complications.

We already use robotic devices in ophthalmic surgery, particularly in refractive surgery and cataract surgery. With keratorefractive laser procedures such as LASIK or lenticule extraction, the surgeon needs these semiautomated lasers to assist in the surgery to produce the most accurate results for our patients. The ophthalmologist examines the patients and determines if they would be suitable candidates for laser vision correction. Then, human judgment is required to determine the degree of laser treatment to be performed and other parameters of the surgery.

In the case of LASIK, the patient is docked to our femtosecond laser, which creates a precise flap. The surgeon pivots the patient to the excimer laser and carefully lifts the corneal flap, and the excimer laser then takes over. This excimer robot will track the eye at hundreds of times per second and deliver the precise laser energy to ablate the desired amount of corneal tissue. The surgeon then replaces the flap and smooths the surface. Clearly, robotic lasers do a large portion of the procedure, but the surgeon is still instrumental in the surgical success.

Robot-assisted cataract surgery is currently in development, with major advances already made and a rapid evolution of the technology. The robotic cataract surgery devices can be used in three modes: remote surgery, assisted surgery and automated surgery.

Remote surgery, also called telesurgery, means that the surgeon is in one location while the robot and the patient are in another location. These two locations can be 10 meters apart or 10,000 kilometers apart while the surgeon uses the controls to perform the surgery.

Assisted surgery allows the robot to improve upon human abilities such as increasing the level of precision, eliminating a tremor or providing increased tactile feedback for tissue manipulation. The robot can also assist with reaction times and can be more than 10 times as fast as a human. For most talented surgeons, a reaction time of 200 milliseconds is typical. For a professional F1 race car driver, this can be as fast as 100 milliseconds. The robot can be 10 times better than that, at just 10 milliseconds or less.

The same applies to data acquisition during surgery. When we operate and look through our microscopes, we take in the world at about 30 frames per second. When you watch a movie or television show, it is shown to you at about this rate, but due to the limitations of the human brain, we perceive it as completely fluid. The robot can use two high-definition, high-speed cameras to acquire three-dimensional video at 100 frames per second or even 1,000 frames per second. The robot also has swept-source OCT imaging, which allows it to see at a resolution beyond what we can perceive, including continually monitoring the position of the posterior capsule. Rupture of the posterior capsule is a potential complication of cataract surgery because this 4 µm thin clear tissue tends to be mobile with the fluid currents of surgery. The robot can visualize it and keep track of it far better than any human surgeon can.

The final frontier is automated surgery, which is still under the watchful eye of the surgeon. We are using forms of this now with femtosecond laser-assisted cataract surgery. Once the surgeon confirms the treatment plan and docks the eye to the laser, the energy delivery to create corneal incisions, perform a capsulotomy and divide the nucleus into fragments is automated. The surgeon can interrupt the robotic laser at any point and take over if needed. All data are analyzed with AI models to continually learn and improve over time.

Using a new robotic system to perform cataract surgery can result in a higher margin of safety, a faster reaction time and earlier detection of issues. The precision is far more than what we can achieve with our hands alone. The robots can also help us improve throughput and allow a surgeon to perform more cases per hour. This is increasingly important as the number of cataract surgeries needed is growing faster than our ability to perform them. One surgeon can supervise multiple robots at once and then pause one or more of them if needed so that the human can take over.

Think of the cataract surgery robot as something similar to the autopilot that is used on commercial airliners. These devices make flying safer, they prevent many types of human error, and they never get tired. Most importantly, these robotic devices, whether in cataract surgery or in airplanes, make it less stressful for us humans. It would be great to have a full day of many dozens of cataract surgeries with a lower level of stress for me as the surgeon.

A video of this can be found at https://cataractcoach.com/?s=robot.

• For more information:
• Uday Devgan, MD, in private practice at Devgan Eye Surgery and a partner at Specialty Surgical Center in Beverly Hills, California, can be reached at devgan@gmail.com; website: www.CataractCoach.com.

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Expert Submission

Disclosures:
Devgan reports being an advisor to Horizon Surgical Systems and owning CataractCoach.com, which is a free teaching website.

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