Do androids dream of the perfect rhexis?

In her shortlisted essay for the 2020 John Henahan Prize, Dr Claudette Veldhuizen looks to the past to imagine the future of robots in cataract surgery

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Claudette Veldhuizen MD
Will cataract surgeons be rendered obsolete by the cold, detached, digital arms of robots? Those who attended the ‘Artificial Intelligence in Ophthalmology’ symposium during the 2019 ESCRS congress in Paris may agree. In some ways, the writing is on the wall: artificial intelligence and robotics seem to be taking over not only in terms of cataract surgery, but ophthalmology, and medicine in general. After all, ophthalmology is an image technology-based specialty. Other image-based fields like radiology and pathology have seen an even faster machine takeover. But are robots creeping their way into the cataract surgeon’s operating room? And perhaps even more importantly: should cataract surgeons, and future cataract surgeons, fear being made redundant, or maybe even worse, irrelevant? Here’s a synopsis of the promises on offer: the developers of microsurgical smart tools are working to steady the surgeon’s hand to a tenth of the human tremor, enabling even the most experienced surgeons to benefit from this technology. Co-manipulation and tele-manipulation allow for human-directed robotic movements into hard-to-reach places with a superhuman range of motion and a far greater accuracy than humanly possible. Also, unlike people, robots don’t get tired or bored – meaning that repetitive tasks become a breeze. In all likelihood, so long as these fields continue to improve, then the stage is indeed set for the future of cataract surgery to move into the realm of robotics. And one can imagine that as with many technological innovations, with time, the technology will become safer and cheaper – and perhaps inevitably, as ubiquitous as the laptop, or in our case, the slit lamp. But is automation per se something to be feared? I would say, not necessarily. Allow me to explain by use of what I believe is the best predictor of the future: the past. Every aspect of civilisation has undergone some form of automation, which includes every human endeavour, from cosmology to agriculture. This pursuit forward has made neither the farmer, nor the cosmologist irrelevant. One could even go so far as to say that in the case of farming, domestication of plants and animals approximately 11,000 years ago directly led to a sharp population growth, which, in turn, only made the farmer even more relevant. New technology means new problems, as well as opportunities for reinvention. More recently, dairy cattle farmers have begun to rely on automated milking by way of robotic arm laser sensors. This move has effectively freed farmers of the traditional rigid grind that manual milking entails, allowing more time for other activities, like supervision. But the farmer isn’t the only winner in this scenario, as more frequent milking also happens to mean happier cows.1 Ophthalmology of course has its own rigid grind – one need only to consider the hundreds of thousands of OCT scans pumped out each year by ophthalmology clinics worldwide. But can we say the same for cataract surgery? Some would certainly say yes, and if not for the whole procedure, at least in part. Femtosecond laser technology already allows for semi-automation, including capsulorhexis and fragmentation. Now pair this with robotic arm laser sensors for automated docking and voilà, we have the idea behind the French-developed KERANOVA. This technology allows for nearly fully automated ‘photoemulsification’ with 80% of the procedure performed sans human interference.2,3 And cataract surgery isn’t alone: the first successful robotic intraocular vitreoretinal surgery has already taken place using the Dutch-developed PRECEYES surgical system.4 In both these examples, the technologies augment and support the abilities of the surgeon. The makers of the PRECEYES even hint that a possible consequence may inadvertently be the extension of the career of the surgeon… However, before we talk any more about the future of cataract surgery, let’s look at the past of cataract surgery: Maharshi Sushruta first described couching as a visual rehabilitation technique in approximately 800BC. If we imagine him being able to time travel over 28 centuries to view how we perform modern phacoemulsification surgery today, he may of course be hesitant, but I imagine that he would attempt to understand and ultimately, embrace our technology – especially given the increased patient safety and precision. We may even slightly smugly envision that he would at least be a little impressed. Cognizant of how far we have come, let’s reconsider the potential grandness of the future of cataract surgery. Perfectionism is a common trait amongst cataract surgeons. Hopefully this drive to create not only visual rehabilitation, but visual performance for our patients, should keep us in good stead, come what may. To conclude, fear, which often manifests as hesitance or reluctance, is hardwired through years of evolution, and is not always without merit. However, perhaps we should aim to translocate and transform it, using it to energise a deep reflection on the profound aspects of cataract surgery that cannot be replaced by robots: the human touch. Robotics and artificial intelligence may promise to open doors and free up our time to further improve our understanding and expertise. However, lest we forget that a gentle touch of the arm of a scared patient lying in the preoperative holding area awaiting surgery, asking with genuine interest if a patient is still doing alright during the procedure, these cannot be replaced. Dr Claudette Veldhuizen MD is a PhD candidate at the University Eye Clinic Maastricht; her research focuses primarily on cystoid macular oedema after cataract surgery
Tags: John Henahan Prize