As the eye care world approaches a possible shortage of ophthalmologists, the steady hand of robotic surgical tools could be a welcome addition for patients undergoing cataract surgery.

Although the days of robotic surgeons or even robotic-assisted surgery in ophthalmology are a thing of the future, Vance Thompson, MD, said that it is not hard to see how robotics could significantly improve a patient’s journey, as well as a surgeon’s experience.

“Robotics have the potential to standardize the level of care and ensure every surgeon, novice or expert, can provide patients with the best clinical outcomes,” he said. “By reducing the natural hand tremor, robotics can significantly improve precision and accuracy, leading to fewer surgical complications.”

Thompson said orthopedic surgery and general surgery have already adopted some forms of robotics, and a few aspects of eye surgery provide a good opportunity to expand automated systems.

“The standardized anatomy of the human eye, coupled with the reproducible steps of cataract surgery, in addition to the colossal global need for more procedures, make cataracts the perfect candidate for robotic surgery,” Thompson said. “Ophthalmology is ready for a robotic revolution.”

The idea of a robotic revolution might be a little threatening for any surgeon, but especially in cataract surgery, where ophthalmologists have invested years learning and mastering microsurgical techniques. When David F. Chang, MD, was first approached by ForSight Robotics, a company developing robotic cataract surgery systems, to head its medical advisory board, he was skeptical. He wondered how microsurgery could ever become fully automated.

“Each of us has honed our skills over thousands of surgeries and many years, so how could a machine possibly emulate that?” he said. “Secondly, why would I want to facilitate development of technology that would put me and my fellow cataract surgeons out of business?”

However, after he learned more, Chang said he started seeing robotics as a potential solution to the global shortage of cataract surgeons, “where we will eventually face severe manpower shortages in even the wealthiest nations.”

“I can see that it’s not only possible, but I think it has a reasonably good chance of succeeding,” he said.

Technology advancements have always been an important part of medicine, and ophthalmology in particular has usually been enthusiastic about finding new ways to improve outcomes. It is no different with robotics, Audrey R. Talley Rostov, MD, said.

“Our goal always is to have things as new as possible to achieve the best outcomes and to achieve them with less invasive technologies,” she said. “That’s just an overarching goal that we all have. We have to think about how we can create safer surgeries, less invasive surgeries and more consistent outcomes. Therefore, it seems certainly reasonable that this is an area worthy of investigation to see if we can use robotics here in cataract surgery.”

Automated processes

Chang said that robotic cataract surgery would initially be semiautonomous with surgeons guiding the robotic arms.

“The most compelling application, however, would be a fully autonomous robot that would do all the steps of cataract surgery while working with a surgical technician,” he said. “But even in that scenario, it would be under the monitoring of an actual cataract surgeon who would be available to step in should there be a complication or safety concern of any kind.”

As for semiautonomous surgery, in some ways, it is already here, John A. Hovanesian, MD, FACS, said.

“I would argue that we’re already doing robotic surgery because femtosecond laser is robotic,” he said. “The use of devices like the precision pulse capsulotomy, also known as Zepto (Centricity Vision), is an automated step that we use that is in a way robotic. Although we haven’t seen these things take huge strides forward, they are in common use, and they do indeed improve on our results. It’s not a new concept to us that we would have some automation involved in surgery.”

Automating some surgical maneuvers has been the key premise of femtosecond laser-assisted cataract surgery, Chang said.

“Although I don’t personally use it, those that do like the reproducibility and precision of an automated capsulotomy,” he said.

Device manufacturers such as Lensar have been incorporating more automated features into their femtosecond laser systems over the last few years, Talley Rostov said.

“They have software that enables better toric alignment with iris registration and with capsular tabs to help orient toric lenses,” she said. “Lensar has the new Ally system that would allow for a combined femto and phaco using essentially the same machine. That automates the process more and increases efficiency with a smaller footprint.”

According to Lensar data, the Ally system can save up to 8 minutes per case compared with other femtosecond laser systems and provides up to a 27% reduction in mean phacoemulsification time compared with manual cataract surgery.

Talley Rostov said that Zeiss has improved femtosecond technology in its refractive surgery platform with the VisuMax 800 system to increase the speed of the process while improving patient comfort.

“It has a robotic arm that comes down that decreases the risk for complications,” she said. “It is also much more ergonomic for the surgeon, as well.”

Robotic assistance

There are a handful of companies currently developing robotic systems for ocular surgery, according to Hovanesian. Some are focused on maneuvers in retina surgery, such as membrane peels that require a lot of dexterity. Hovanesian said it is not hard to imagine that translating to cataract surgery.

“If we have the precision of a human guiding a machine to grasp tissue and not damage the surrounding tissue, that could, indeed, offer some help,” he said. “We’re optimistic about these companies that have good funding all over the world, and I think it’s pretty likely that we’re going to have some meaningful progress on this within the next decade or maybe even sooner.”

One of those companies is ForSight, which is developing the ORYOM platform. The system includes a robotic hand, enhanced 3D visualization and improved data analytics designed to help improve surgical techniques.

Chang, who had a chance to test the platform in animal eyes, said the surgeon operates at a workstation about 12 feet away from the OR table maneuvering robotic arms that mirror a surgeon’s movements through every stage of the surgery.

“Several of us from the medical advisory board got to try this system,” he said. “I think we all came away quite impressed with the feasibility of semiautonomous robotic surgery.”

Chang delivered the Charles D. Kelman, MD, Innovator’s Lecture at the American Society of Cataract and Refractive Surgery meeting in Boston and shared footage of him performing a complete operation in a porcine eye with the ORYOM platform. He also discussed how AI-powered machine learning software might someday enable fully autonomous robotic cataract surgery.

“It’s exciting because this is the 50th anniversary of ASCRS,” he said. “During the last 5 decades, we’ve seen cataract surgery evolve from intracapsular surgery and aphakia to extracapsular surgery with lens implants to sutureless incisions with phacoemulsification and foldable IOLs, and then automating the capsulotomy with either femtosecond laser or Zepto — is this the next evolutionary step?”

Thompson also had a chance to test the platform and called his experience a peek into the future of surgical eye care.

“The addition of augmentation and real-time image guidance, as developed by ForSight Robotics in their surgical robotics platform, for example, can also alleviate cognitive stress, thus providing surgeons with a holistic solution for improving our health and capabilities, ultimately helping us serve our patients better,” he said.

Hovanesian said introducing more automation into the cataract surgery process has the potential to improve factors with innovative technology, making surgery more consistent, more widely available and more efficient.

“If you don’t give the patient the vision they anticipate, then you failed, even if it was an uncomplicated surgery,” he said. “These systems will target the same things as we look ahead to a workforce shortage among doctors.”

Robotics have the potential to fill in some gaps as more patients will likely undergo surgery at greater rates and with greater expectations. Hovanesian said cataract surgeons must embrace whatever they can to make the process better.

“Our profession is filled with many capable surgeons who have very low complications rates,” he said. “Many of these surgeons don’t ever give lectures — they are just doing what they’re doing in their communities with a lot of skill. But not everyone has that level of skill, and there are many communities across the country where they don’t have a skilled surgeon. Complications can happen.”

Looking beyond the United States, automation may provide a lot of benefits for patients.

“If we could take steps toward automation, we would improve humanity’s outlook,” Hovanesian said. “Cataracts are still one of the leading causes of blindness across the world.”

Thompson said one area in which robotics could make a substantial impact is in training because it can take years for a physician to prepare for cataract surgery.

“Today, it takes an average of 15 years to train an ophthalmologist, and a lifetime of practice and growth to improve surgical skill,” he said. “Novice surgeons or surgeons with limited access to advancement opportunities like top-tier residency programs, fellowships or mentors are at a disadvantage and may take much longer to reach their full potential. Robotics can shorten the learning curve by providing all ophthalmic surgeons with a system that improves dexterity, precision and accuracy, thus standardizing the highest level of surgical techniques.”

According to Chang, the historically large backlog of cataract blindness in low- to middle-income countries is primarily due to a shortage of ophthalmologists.

“However, we’ll soon be facing a shortage of cataract surgeons in high-income countries as well due to aging populations and our limited capacity to train enough new surgeons,” he said. “Taking steps toward fully automating the process has the potential to address these challenges.”

“Another factor that many are overlooking is what I believe will be a rapid rise in refractive lens exchange volume,” he said. “As adjustable and accommodating IOLs propel this demand in presbyopic patients without cataracts, who is going to do all these surgeries?”

Chang fantasizes that a single surgeon could simultaneously monitor multiple autonomous robotic systems operating on routine cataracts and refractive lens exchange eyes. Complex cases would still be done by ophthalmologists.

“Such a system could expand the capacity of individual surgeons in even high-income countries to do higher volumes of cataract surgery with good outcomes,” he said.

Thompson said robotics have the potential to improve precision and reduce a surgeon’s natural hand tremor, which is particularly important in a small organ such as the eye. They also have the ability to consume large amounts of data and provide real-time insights that a surgeon might need, he said.

“Final refractive clinical outcomes are dependent on perioperative, operative and postoperative information,” Thompson said. “Today we gather a large amount of information prior to operating. However, we do not have enough data analysis during and after operation to reach actionable insights on a large scale. Robotics enable the synthesis, prioritization and optimization of data from the patient’s journey. This process can standardize better clinical outcomes and elevate the quality of our care.”

A human touch

Talley Rostov views robotics as an addition to a surgeon’s skill, not a replacement.

“I see robotic surgery as another tool or maybe the next step in creating more consistent outcomes,” she said. “There is, of course, the challenge of making this accessible globally. I do a lot of global health work, and in many parts of the world and underserved areas, your best option is actual manual small-incision cataract surgery because they don’t even have access to phaco capability.”

Hovanesian said no computer or machine ever created has come close to what can be accomplished with the human mind. Even if robotics can come close, that would likely be many years away.

“We often recognize patterns without consciously knowing what we’re thinking. As a surgeon progresses through his or her career, we can just get better at what we do because we’ve seen so many different variations of the same thing. Computers are not going to have that experience even if they watch the videos because the videos can’t capture all the nuance or get the same tactile feedback that we see through a binocular microscope in real time as we operate,” he said.

“For a routine soft cataract in uncomplicated eyes, a machine could probably do pretty well. However, if you have a case with a small pupil, pseudoexfoliation and other risk factors that can lead to a poor outcome, it’s hard to imagine at least the first generation of computer systems mapping that,” Hovanesian said. “We’re still the best hope for our patients, but we ought to welcome these technologies and be humble about the fact that, at some point, they may become better than us.”

Even as these technologies progress, they will still require some degree of skill from an experienced surgeon to be successful, Talley Rostov said.

“It’s another tool in your armamentarium, another tool in the toolbox,” she said. “Just because something is more automated doesn’t mean that your skills aren’t required. When phaco was introduced, it didn’t eliminate the need for surgeons who had trained with the extracapsular technique.”

Thompson said advancing technologies are part of the changing world, and it is up to surgeons to adapt. No matter what technology comes into play for cataract surgery, surgeons will always be required, just like pilots are still needed despite most flights being completed on autopilot, he said.

“Human surgeons will always need to be in the loop, both in case of complications during surgery and to simply hold a patient’s hand,” he said. “One of the main reasons I love practicing surgery is because I have the privilege of interacting with so many patients every day. Their smile after receiving the gift of sight again is priceless. I believe the implementation of robotics will help make their smiles even bigger, as more patients will have better access to the best refractive outcomes.”