Robotics on the horizon for cataract, IOL surgery
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The long definition of a robot from the internet:
“Robotics combines science, engineering and technology to design, construct, operate and use machines programmed to replicate, substitute or assist humans in completing tasks of varying complexity.”
There are many types of robots, but those most interesting to we ophthalmic surgeons are surgical robots. Most surgical robots today are actually articulating cobots in which a mechanical arm attached to a machine with a visualization system collaborates with a living human to accomplish a surgical task. Articulating cobots are designed to enhance, not replace, a well-trained surgeon. The best example of an articulating cobot is the da Vinci surgical system (Intuitive Surgical). It is also possible to design a humanoid robot that imitates human behavior and thought process and is designed to replace a living human surgeon. Fortunately for we human surgeons, humanoid robots are a decade or more away. But articulating cobots are here today, and the first generation of cobots used in eye surgery is represented by the excimer and femtosecond lasers. For the rest of this perspective, I will use the term robot, which is more familiar to most than cobot.
Mechanical engineering, electrical engineering, laser science, computer science, machine learning and artificial intelligence are all critically important in developing a surgical robot. Progress in the field of robotics is nothing short of amazing and accelerating. While we humans have been using machines for centuries, the first industrial robot was developed in 1954 and first applied in automotive manufacturing in 1961 by General Motors. We are all familiar with the impact robotics has had in that industry.
In surgery, Intuitive Surgical was founded in 1995 and received FDA approval for the first-generation da Vinci surgical system in 2000. In 2000, Intuitive raised $46 million in an initial public offering and placed the first da Vinci devices in a U.S. hospital. Today, a mere 30 years later, there are more than 5,500 da Vinci surgical systems in use worldwide. The newest-generation da Vinci Xi system costs approximately $2 million, and in 2023, Nasdaq-traded Intuitive Surgical generated $7.1 billion in revenue and today boasts a $140 billion market cap.
Advocates argue application of the da Vinci surgical system has made many surgery procedures less invasive, more reproducible in outcome, and safer with a lower intraoperative and postoperative complication rate and morbidity. Detractors point to increased cost and argue the touted benefits are unconfirmed. The debates among robotic surgeon advocates and robotic surgeon detractors are like those we have heard before regarding phacoemulsification and, at present, femtosecond laser-assisted cataract surgery. But as the late Charles Kelman, MD, repeatedly stated: “While doctors debate, patients decide.”
Being both a doctor and a patient, I decided to undergo an Intuitive Surgical da Vinci surgical system robotic total prostatectomy at UC Irvine when I developed biopsy-positive prostate cancer just more than a decade ago because it was minimally invasive compared with the alternative classic large-incision anterior approach and promised a lower complication rate with less postoperative morbidity. I am happy with my choice even though it required some increase in out-of-pocket cost. So, I am an advocate for a robot that enhances but not replaces a human surgeon as both a surgeon and a patient.
Now to ophthalmology. First, a disclosure. The two leading companies developing surgical robots for cataract/IOL surgery are ForSight Robotics and Horizon Surgical Systems. Some of the interviewed ophthalmologists for this issue’s cover story consult for ForSight Robotics. I serve as chair of the medical advisory board and consult for Horizon Surgical Systems. Both companies are dedicated to developing a robotic surgical system that enhances the outcomes of cataract/IOL surgery without replacing the ophthalmic surgeon. These companies are both well funded and supported by outstanding teams. I believe we can expect to see robots in daily use by ophthalmic surgeons by 2030.
I expect robots to enter cataract/IOL surgery initially through the cash-pay premium channel. With OCT guidance, they promise micron accuracy in instrument movement, and with the application of machine learning and artificial intelligence, surgical outcomes can be expected to continuously improve. While cataract/IOL surgery performed by the best high-volume surgeons today is exemplary, many less experienced and lower-volume surgeons are challenged with the creation of a perfectly sized and centered capsulorrhexis as well as the efficient, safe and atraumatic removal of the natural lens. Patients have proven they are willing to pay for improved outcomes and especially for enhanced safety. Hospitals and ASCs are willing to pay for increased patient volume and enhanced efficiency. If an eye surgery robot can help make cataract/IOL surgery safer and perhaps more efficient, especially if it drives increased patient volume, we will see one or more companies evolve in ophthalmology that emulate the success of Intuitive Surgical.
For ophthalmic surgeons with more than a decade left to practice, I strongly believe they will employ and they and their patients will benefit from a robotic-assisted surgical workstation, which will include a sophisticated visualization system, a femtosecond laser and artificial intelligence. This will represent another example of investment and innovation benefiting we ophthalmologists and our patients.
- Reference:
- What is robotics? https://formant.io/robotics/. Accessed March 25, 2024.
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