Technological innovations coming for ocular surgery
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Oftentimes, the younger generation has insight into the future of our field, especially when it comes to incorporating new technological advances.
In this column, Aarun Devgan explores three innovations that are rapidly integrating high tech with ophthalmology.
We already use advanced technology in our operating rooms to give patients their best vision with a high safety record. While we think this is the pinnacle of ocular surgery, the future will bring more technological innovations. These transformative advancements include virtual and augmented reality, assistance from artificial intelligence and robotic surgical instrumentation.
Virtual and augmented reality
Virtual reality (VR) has been around for some time, making strides in the consumer market, and now it has proven fruitful for visual field testing. Studies have shown that VR headsets are capable of matching the accuracy of the Humphrey Visual Field Analyzer (Zeiss). These new VR field analyzers are a fraction of the size and cost of the older, traditional diagnostic hardware devices. The cost of the VR headsets will trend even lower, which will allow more widespread testing and accessibility to patients. Figure 1 shows a low-cost VR visual field machine utilizing a smartphone algorithm for quick and accurate visual field testing.
In the cataract education space, VR headsets can be used to demonstrate the visual outcomes of different IOL designs on the quality and range of vision after surgery. This helps patients decide which IOL designs are best suited to their needs and desires.
In the operating room, we have augmented reality in place with the newer generation of surgical video viewing systems. These systems allow a surgeon to benefit from guidance reference marks for the creation of the capsulorrhexis and astigmatic alignment of toric IOLs and placement of corneal relaxing incisions. Figure 2 shows this setup in use for routine cataract surgery. Even more advances such as different color filters and infrared visualization systems are on the horizon.
Robotic surgical assistance
When LASIK was first performed, a mechanical microkeratome was used to create the corneal flap. This was then upgraded to a motorized microkeratome and then finally to an automated femtosecond laser. This is a form of robotic surgical assistance in which the femtosecond laser can create a better and more precise corneal flap, with a higher safety margin, than we could ever create by hand.
The surgeon’s eyes perceive 30 frames per second as fluid and smooth video, and reaction time is about 200 milliseconds. We can have robotic devices evaluate the surgical field at a rate of 300 or more frames per second using both video and OCT for even more precision. Reaction time for the robotic devices will be about 2 milliseconds. This means that the robotic devices, supervised by human surgeons, will allow for 10 times the frame rate and 100 times the reaction time.
Even in situations where the surgeon is going to manually perform a delicate task, such as peeling an epiretinal membrane that is just a few microns thin, the robot can aid in providing more precision. There can be a stepdown in the movement by a factor of 20 or more so that a 1 mm movement by the surgeon outside the eye translates to a 0.05 mm movement inside the eye. We can even add tactile feedback through the robotic controls in a procedure that usually has zero tactile sensation for the surgeon.
Artificial intelligence guidance
Ophthalmologists can tell the relative age of a patient by looking at a fundus photo of the retina and if the patient has certain systemic diseases such as diabetes or hypertension. New artificial intelligence systems can analyze these same photos and tell the age to within a few years, determine the gender of the patient and give more insights than humans ever could. Using AI to screen retinal fundus photos is becoming more common, and this will soon extend to analyzing corneal topographies, visual field testing, nerve fiber layers and more.
For IOL calculations for cataract surgery, we have found that there is no one formula that is accurate for all eyes. While most static formulas are stuck at about the 80% accuracy level of ±0.5 D, newer methods such as the evolving AI formulas can give surgeons accuracy of greater than 90%. This will soon apply to keratorefractive surgery, astigmatic corrections and more.
The AI and machine learning algorithms will also mesh with the robotic devices to provide intraoperative improvements in accuracy, efficiency and safety.
The future of ocular surgery will continue to evolve, with technological advances in virtual and augmented reality, robotic surgical assistance and artificial intelligence algorithms aiding ophthalmologists. We will be able to give our patients the best vision with a high margin of safety and unprecedented precision.
- For more information:
- Aarun Devgan, a graduate of Dartmouth College with an honors degree in neuroscience who will start medical school this fall, can be reached at aarundevgan@gmail.com.
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