Getting a Clearer View of a High-Tech Future

Looking for the future of cataract and refractive surgery? The 2023 Congress of the ESCRS in Vienna was the place to be. Beginning with the iNovation sessions on the digital OR, Clinical Research Symposia on the Truths and Myths of Digitization, and even the final day’s sessions on automating eye surgery and embracing AI, the technological promise of the future was the topic of the moment.

The ESCRS Clinical Research Symposium session “Cataract and Refractive Surgery in 2030” looked at the near future from the current debates regarding various techniques and technologies within these fields.

Dr Alexander Day began by raising the question of whether technological innovations will make femtosecond laser-assisted cataract surgery (FLACS) better than phacoemulsification for cataract removal.

“Clearly, there is a lot of work that needs to be done,” Dr Day told attendees, explaining that currently, femtosecond lasers perform only 5 of the 10 steps needed to complete cataract surgery and only do some of the 5 steps well.

“In brief, FLACS platforms are expensive devices for capsulotomy and astigmatic keratotomy,” he said.

Reviewing evidence from large randomised controlled trials showing no true advantages of FLACS versus phacoemulsification, he noted that while the FLACS systems are well-established platforms, there has generally been very little industry investment recently in its research and development.

Dr Day observed several research questions need to be answered to establish the role of FLACS versus phacoemulsification, mostly relating to the need for evidence on specific clinical outcomes—e.g., effects on dysphotopsia rates and presbyopia-correcting IOL outcomes. He also cited a need to investigate potential novel applications.

Waiting for the robots

Addressing robotics as the future of cataract surgery, Dr Jean-Pierre Hubschman said that although there is currently perfect visualisation and high manoeuvrability, robotics technology can help address existing challenges on multiple fronts.

“We are still facing a shortage of surgeons and staff and increasing demand for surgery,” he said. “There are also current technological and human limitations and inconsistent outcomes impacted by different surgeon skill sets.”

Dr Hubschman briefly reviewed the two robotics platforms developed for ophthalmology and successfully tested in humans, both with retinal applications. He went on to describe a fully integrated, image-guided, AI-enabled microsurgery platform in development specifically for cataract surgery. This system has demonstrated a capability for performing every surgical step and promising outcomes in cadaver and porcine eye models.

Concluding, Dr Hubschman said robotics will improve every surgical step in cataract surgery, provide surgeons AI-driven insights for peak performance, significantly reduce complications, and increase throughput.

“Surgery is an art, and today, depending on the surgeon, the outcomes may be very different from one to another,” he observed. “With robotics technology, we can make cataract surgery a science and allow every patient and every surgeon to achieve the best care.”

An accommodating IOL in 2024?

Professor Jorge L Alió set expectations for the future of presbyopia- correcting IOL technology in his talk, “A working accommodative IOL: fact or fiction?”.

“Once accommodating IOLs are developed adequately, multifocal IOLs will be unable to compete, as happened with pseudophakic glasses and IOLs,” Prof Alió said.

He focused on the research surrounding the Lumina accommodating IOL his group developed, which will be commercially available in 2024.

Explaining the rationale for the sulcus location of this lens, Prof Alió said, “The capsular bag seems to be a wrong location for accommodating IOLs due to its unavoidable decadence and fibrosis once the crystalline lens is emptied. The forces generated at the zonular-anterior capsule system are those to be used for accommodating IOLs. Sulcus implantation is the only option.”

To demonstrate, Prof Alió presented a video of the IOL implantation, which is performed through a 2.75 to 3.00 mm incision and reviewed outcomes, including data on accommodative range and stability, visual acuity and refraction, contrast sensitivity, visual quality, patient satisfaction, and results after YAG laser capsulotomy.

Prof Alió said the Lumina accommodative IOL effectively restores the visual performance for far distance vision with functional performance for intermediate and near vision with good contrast sensitivity in presbyopic patients after cataract surgery. The accommodative range is variable, between 1.0 and 3.0 D, with accommodation and pseudo-accommodation justifying part of the near-vision outcomes. Its vision performance is a continuous range of distance from far to intermediate and near distances, with interindividual variability. Near-vision outcomes correlate well with high satisfaction levels of the implanted patients. It appears that an intact posterior capsule is not necessary for pseudophakic accommodation. Therefore, the Lumina can be implanted safely and successfully following a capsular break.

Flap versus lenticule

Turning to refractive surgery, former ESCRS President Professor Béatrice Cochener-Lamard offered her thoughts on the future of flap or lenticule-based refractive procedures.

She noted that femto-LASIK is the gold standard even though lenticular surgery was “born” to overcome the limitations of the flap-based procedure. A portion of her talk reviewed the advantages, limitations, and outcomes of SMILE, which she referred to as the “pioneer” in lenticule-based procedures. This procedure has expanded over the years and has advanced with the development of a new-generation femtosecond laser.

Prof Cochener-Lamard also described three new upcoming platforms for lenticular surgery and suggested the new competitors may attract more surgeons to try lenticular refractive surgery. She anticipates more data on lenticular implantation surgical procedures for treating hyperopia, presbyopia, ectasia, and aphakia and correcting pathological corneal thinning.

“In 10 years, I guarantee surface ablations will not be obsolete because we will still have some specific indications for these procedures,” Prof Cochener-Lamard observed.

“[Lenticular surgery] does have a promising future, and it may be competitive for LASIK, but I cannot guess if it can replace it.”

AI assistant

The future of AI for guiding surgeon decision-making was discussed by Dr David Smadja, who proposed that through its ability to process a large amount of data, AI will be especially helpful when choosing appropriate candidates for surgical procedures and the right procedure for each. He cautioned surgeons to be aware of its limitations because its performance depends on the training data set.

Dr Smadja also explained how AI could help in predicting and improving surgery outcomes, improve knowledge, save time, and assist with some aspects of manuscript preparation.

“There is no doubt. The AI wave is here,” Dr Smadja said. “We just have to learn how to surf.”

EuroTimes will provide detailed coverage of the specific issues and topics raised here in separate articles in this and future issues.

Alex Day PhD, FRCOphth is a consultant ophthalmic surgeon at Moorfields Eye Hospital, London, UK. alex.day@ucl.ac.uk

Jean-Pierre Hubschman MD is Professor in Ophthalmology and Mechanical and Aerospace Engineering, Los Angeles, California, US. jphubschman@horizonsurgicalsystems.com; Hubschman@jsei.ucla.edu

Jorge L Alió MD, PhD is Medical Director at Vissum Innovation and Professor and Chairman of Ophthalmology at Universidad Miguel Hernández, Alicante, Spain. jlalio@vissum.com; jlalio@vissum.com

Béatrice Cochener-Lamard MD, PhD is the Head of the Ophthalmology Department at Brest University, France. She is a former president of the ESCRS. beatrice.cochener-lamard@chu-brest.fr

David Smadja MD, PhD is the Director of the Refractive Surgery Unit at Hadassah Medical Center, Tel Aviv, Israel. smadj.david@gmail.com