Piecing Together a Solution

The launch of the da Vinci system at the start of the new mil­lennium set a milestone for medical robotics, rapidly becom­ing a valuable option for microsurgery. According to Jean- Pierre Hubschman MD, the success of this kind of technology was just the beginning.

“The da Vinci system has already revolutionised laparo­scopic surgery, and since then, it has been redesigned and commercialised for other applications like general, paediatric, and cardiac surgery, with more than 7,000 platforms adopted worldwide,” he said. “This is a technology that can really pro­vide some outstanding performance by enhancing surgeons’ manoeuvrability and precision, translating into improved out­comes with shorter hospital stays and fewer complications. It is a solution that may open the door for new surgical tech­niques, and that will eventually lower the cost of surgery.”

Despite the success in many different surgical fields, the da Vinci system was unable to break through in ophthalmology. A possible explanation for this could be that eye surgery is already a precise and minimally invasive microsurgery with low complication rates and exceptional precision. “It is not a good system for eye surgery,” Marc de Smet MD, PhD said. “Da Vinci has proved its efficiency in urology because a certain degree of precision is needed when you want to avoid vessels. But we are talking about the precision in the millimetre range, not precision in micrometre range as eye surgery demands.”

Particularly in the anterior segment, high levels of stan­dardisation with low rates of complications have led to a general lack of interest in robotics among cataract surgeons, whereas refractive surgery has already used it since the late 1980s. “A robotic system does not necessarily have arms,” Dr de Smet explained. “Laser is indeed a form of robotic surgery. Therefore, robotics is already a core part of eye surgery.”

Automation is already a reality for refractive surgery, explained Diego de Ortueta MD, PhD. “We have devices that collect a lot of information from the patient and calculate the best outcomes. However, not every system—not even transPRK—can be performed without the help of a surgeon.”

Who needs robots?

However, from the point of view of cataract surgery, inter­est is dwindling. Dr de Ortueta noted this is also due to the negative outcomes in cost-effectiveness of femtosecond-as­sisted cataract surgery (FLACS). “There is scarce evidence in the literature showing FLACS to be better than the standard procedure. Maybe in the future that could be better, but right now it is not, and the costs are much higher,” he said. “The main point is this: if we are so good at doing surgery, why should we let a robot do our surgery instead?”

On the other hand, the demand for the high levels of pre­cision provided by a robotic arm found fertile ground in the field of vitreoretinal surgery, especially when considering sub­retinal injections. “If we want to hit a bleb size of 0.1 mm, the maximum volume that we can inject is only 0.1 microlitres. I would challenge anyone to be able to know where to stop injecting at that volume,” Robert MacLaren noted. “If you want to inject an 800,000-euro gene therapy treatment subret­inally, you have to do everything possible to be sure that you are doing it safely. One of the greatest advantages of having a robotic system would be to slow the infusion rate to minimise the risk of retinal stretch. The advantage of using a robot as a delivery system is to increase precision at a point you can avoid reflux—thus reducing the risk of an immune response, while also reducing the quantity of drug in your syringe.”

Into the black box

The astonishing, and in some respects controversial, boom of AI has deeply affected every aspect of our daily living. Ophthalmology is no exception. It is one of the medical fields that saw the earliest application of artificial intelli­gence in advanced imaging, and the potential for further developments is indeed high.

“AI is changing the way we do everything, from ChatGPT to Autopilot, it is all around us,” Dr Hubschman pointed out. “It is a technology that is going to deeply change med­icine and surgery. It has the ability to accumulate an unlim­ited amount of knowledge, identify new trends, and solve complex problems. Soon it will help surgeons make the right decision, plan surgeries, assess and even execute different surgical steps.”

“If you want a procedure or a task to work well in a robot, you have to program the robot with a good mathematical al­gorithm telling the robot what movements it needs to make,” Dr de Smet said. “AI can take information from multiple oper­ations, giving good results with just a hundred different cases. Right now, it can provide us with the best parameters. And in the future, it will probably help identify the best starting point for surgery—or, in the distant future, eventually doing the surgery for us.”

“The biggest problem is that a surgeon understands what the machine does but not the calculations inside the black box. Who or what will decide in the end what could be the best option for the patient?” Dr de Ortueta asked. “In the future, all of this could be fully automated, but an AI making decisions would have clear ethical issues. For example, what if automation would answer more to the logic of the industry than the needs of the sur geon, sug­gesting SMILE every time instead of the best option for the patient? As ABBA says, ‘the winner takes it all,’ as the in ­dustry may decide things that we surgeons are not capable of fully understanding.”

Waiting for the leap of faith

When speaking of partial automation of surgery, the relation­ship between the physician and the industry is complex. Despite robotics becoming a growing reality in medicine, its presence in anterior and posterior ocular microsurgery is still scarce.

“For years I’ve debated why investors do not come for­ward in the field of robotics,” Dr de Smet said. “Essentially, a company must take a leap of faith before the others will be willing to follow. There is a lot of work that must go into the making of a robotic system, and it takes quite a while to get something that properly works. Then you must sell enough units, and only then you get to a point where suddenly inves­tors and money become available.”

According to Dr de Ortueta, this reluctance of the ophthal­mic industry may also be driven by scepticism in the medical community. “If a device starts performing worse than the surgeon itself, would it be worth investing? Perhaps when the number of patients will increase to the point that we will not have sufficient resources to treat them all, and maybe when technology will be able to provide a certain degree of safety and efficacy, things will start to change.

“We will eventually end up with full automation of surgery, but right now, we would have to deal with higher rates of complications compared to standard cataract surgery. Industry will preferably invest in other fields of medicine like urology, where these rates are already much higher.”

Things are only recently starting to slowly move in the right direction. Dr de Smet reported the University of Califor­nia, Los Angeles, has developed a commercial application for cataract, with companies in Israel and Lyon, France, doing the same. “Other platforms for general surgery, like Medtronic, are already challenging da Vinci,” he said. “So, I think that it is coming, I just don’t know when all will finally take off, but it is sure that a big change is coming.”

Jean-Pierre Hubschman MD is Co-Founder and CEO at Horizon Surgical Systems, California, US. jphubschman@horizonsurgicalsystems.com

Marc de Smet MDCM, PhD, FRCSC is Founder and Executive Director of Microinvasive Ocular Surgery Clinic (MIOS) and CMO of PrecEyes (a Zeiss Company). mddesmet1@mac.com

Diego de Ortueta MD, PhD is Medical Director at the Augenlaserzentrum Recklinghausen, Germany. Diego.de.Ortueta@augenzentrum.org

Robert MacLaren MB, ChB, DPhil is a Professor of Ophthalmology at the University of Oxford, UK. robert.maclaren@eye.ox.ac.uk