AI-Guided Robotics Elevate Cataract Surgery

Robotic cataract surgery is no longer just a dream. With today’s femtosecond laser assistance systems, robotics are already in use in operating theatres.

Rather than take over surgery autonomously, modern robotics provide surgeons with precision guidance to optimise nearly every step of cataract surgery, explained Dagny Zhu MD. The technology helps surgeons analyse and plan surgeries and increase the safety of delicate manoeuvres inside the eye, keeping them firmly in control.

For example, the Lensar ALLY system uses iris registration guided by artificial intelligence to precisely direct incisions and toric placement. Capsulotomies are precisely centred on the optical axis, which is especially important for optimising multifocal lens performance, said Dr Zhu, who implants premium lenses in about 90% of her cataract patients and uses a femtosecond laser in virtually all cases.

AI also helps image cataracts and determine their density to recommend fragmentation patterns that research suggests can reduce phacoemulsification energy requirements and capsule ruptures, Dr Zhu added. Such automated arcuate incision planning and precise placement result in more accurate and stable astigmatism corrections.

“All of this is done semi-autonomously, meaning the surgeon is there to guide every step of the way and supervise this robotic intelligence,” Dr Zhu said. “Robotic cataract surgery exists, or at least robotic laser-assisted cataract surgery.”

Future directions

Robotic cataract surgery conjures images of robots performing every step of surgery independently, “with perfect precision, without any input from the surgeon whatsoever. . . . There’s always this fear of this happening when you let robotics take over,” Dr Zhu said.

However, autonomous robotic cataract surgery lies far in the future, if it is possible at all, and will always require surgeon supervision, Dr Zhu said. Today’s cataract robotics are mostly surgeon-controlled, although semi-autonomous systems with combined robot and surgeon control are in use, with many more in development.

Current robotic surgery platforms fall into three categories, Dr Zhu noted. One type includes handheld smart tools with all the technology built into the handle, helping make surgical manoeuvres more precise. Another type are co-manipulation systems in which dedicated tools are controlled by robotic manipulators and the surgeon. And there are telemanipulation systems in which robotic manipulators separate from the surgeon are controlled from a surgical cockpit.

Robotic retinal surgery already exists, using both handheld and direct surgeon control devices, Dr Zhu said. They improve precision by reducing hand tremors, making delicate manoeuvres such as peeling epiretinal membranes or cannulising retinal arteries safer. “These are difficult to perform even for the best retinal surgeons.”

Other potential advantages of robotic systems include better visualisation and spatial perception, haptics for improved tactile feedback, greater manoeuvrability in the eye, and reduced reaction time. Robotics also enable better integration of OCT and other imaging technologies, both to guide surgery and create safety zones that prevent instruments from getting too close to fragile structures, such as the corneal endothelium and posterior capsule.

Robotic cataract surgery using telemanipulation is already in development, Dr Zhu said. One system has been used to perform entire cataract procedures on an animal model in a different room from the control console.

“Will robots ever replace surgeons?” Dr Zhu said. “Not completely. They will always work on the side of the good—assisting us in doing the best we can and making our current surgery even better.”

Dr Zhu made her remarks at the 2025 ESCRS Annual Congress in Copenhagen.

Dagny Zhu MD is medical director and partner at NVISION Eye Centers, Rowland Heights, California, US. Dagny.Zhu@nvisioncenters.com