Robotics may be next step in modernizing laser cataract surgery

ByStephen G. Slade, MD

Fact checked byChristine Klimanskis, ELS

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It is hard to believe that 17 years have passed since Zoltan Z. Nagy, MD, PhD, performed the first femtosecond laser-assisted cataract surgery procedure worldwide.

At the time, the main advantages of the procedure over conventional cataract surgery included greater predictability and reproducibility of the capsulotomy and corneal incision (Nagy et al.).

Figure 1. The surgeon controls the procedure — reviewing, confirming and accepting the surgical plan — while the robotic system provides the highest precision, accuracy and consistency. *Stephen G. Slade, MD, FACS*

Laser cataract surgery has evolved since 2008. Studies from the early years of the technology demonstrated improvements in outcomes, but there was still room for growth in fluidics, nucleus fragmentation and overall efficiency. More recent evidence showed statistically significant differences in several surgical parameters, including a decrease in total and effective phacoemulsification time, cumulative dissipated energy use, postoperative central corneal thickness and endothelial cell loss (Kolb et al.; Popovic et al.). Currently, robotics is being introduced to laser cataract surgery to not only further improve surgical outcomes but streamline the surgical procedure for both surgeons and patients.

Among the first wave

I was among the earliest wave of laser cataract surgery adopters and performed the first procedures in the United States in 2010. Although the technology was in its infancy, it was an exciting time of innovation and discovery. Over the years, I gained experience with almost all the available femtosecond laser systems, including LenSx (Alcon), Victus (Bausch + Lomb), Catalys (Johnson & Johnson Vision), Ally (Lensar) and Femto LDV (Ziemer). Now, more than a decade later, I am excited by the next natural step — the integration of robotics into cataract surgery.

Stephen G. Slade

For robotics to work in ophthalmology, there must be defined interactions between a surgeon and a laser system. The surgeon remains in control of the procedure — reviewing, confirming and accepting the surgical plan — while the robotic system provides guidance, precision and consistency that human hands alone cannot achieve (Figure 1). In this way, every step of the cataract surgery procedure may be optimized. While I don’t think cataract surgery will be fully robotic in my lifetime, consistent forward progress is being made with the Ally system. The combination of robotic intelligence and precision with our surgical experience and expertise helps us deliver the most advanced cataract surgery procedure possible.

The role of robotics

One key advancement in laser cataract surgery is Ally’s use of robotic docking to monitor IOP throughout the procedure, ensuring stability and safety. Additionally, the laser’s imaging capabilities — backed by the computational power of thousands of data points analyzed with AI — provide key points of reference such as iris registration, surface detection and cataract density. With such a robust image analysis, treatment plans are tailored and account for variables such as lens density, thickness and patient history. The ability to scan the nucleus and compare it to a database of previous cases allows the system to suggest optimal energy settings and fluid usage. These AI-driven insights also support a procedure that uses the least amount of laser energy while ensuring surgical precision.

Intraoperatively, a robotic-guided laser system replaces human macro-movements with robotic micro-movements to create reproducible capsulotomies, incisions and lens fragmentation patterns. It also compensates for patient movements in real time. As a result, the procedure is not only more consistent but also gentler on the eye, promoting faster healing and minimizing postoperative inflammation.

The incorporation of robotics also broadens the scope for astigmatism management. With advancements such as IntelliAxis, Ally may now be used to treat both low and high astigmatism. Studies have shown that up to 100% of patients who received a toric IOL and up to 95.8% treated with arcuate incisions were within ±0.5 D of the intended refraction (Visco et al.; Stephenson).

The level of efficiency gained with robotic-assisted cataract surgery is unparalleled. The combination of automation with robotic speed and precision provides a flexible workflow that helps reduce total surgical time by up to 8 minutes per case compared with other laser cataract surgery systems (Visco) while leaving the surgeon in control of the procedure. Ally’s software allows me to adjust energy settings, incision placement and treatment parameters based on my expertise and the unique characteristics of an eye.

Visualization for both the surgeon and their team is excellent. Multiple monitors display critical data, enhancing communication and ensuring everyone is aligned during the procedure.

Meeting patient expectations

Today’s cataract patients have high expectations. Many anticipate LASIK-like results and expect perfect vision the day after surgery. While this outcome is not always realistic, it underscores the need for technology that can deliver “wow factor” outcomes. Robotic-assisted cataract surgery provides the tools to meet these expectations by enhancing precision, reducing variability and minimizing recovery time.

The integration of AI and robotics into cataract surgery is not just about improving outcomes; it is about creating a better patient experience. Faster healing times, more eyes at 20/20 uncorrected visual acuity on day 1 and less invasive procedures contribute to higher patient satisfaction. For surgeons, these advancements mean greater confidence in achieving optimal outcomes, even in challenging cases.

Conclusion

Current advancements in robotic technology are setting the stage for a new era of cataract surgery. While fully robotic cataract surgery remains a vision for the future, each new iteration of technology helps us improve outcomes and redefine what is possible in ophthalmology.

For more information:

Stephen G. Slade, MD, FACS, a cataract and refractive surgeon in private practice at Slade & Baker Vision in Houston and a Healio | OSN Refractive Surgery Board Member, can be reached at sgs@visiontexas.com.

References:

Kolb CM, et al. J Cataract Refract Surg. 2020;doi:10.1097/j.jcrs.0000000000000228.
Nagy ZZ, et al. J Refract Surg. 2014;doi:10.3928/1081597X-20140711-04.
Popovic M, et al. Ophthalmology. 2016;doi:10.1016/j.ophtha.2016.07.005.
Stephenson PDG. Femtosecond laser-assisted capsular marks and ORA to guide toric IOL alignment during cataract surgery. Presented at: American Society of Cataract and Refractive Surgery meeting; May 3-7, 2019; San Diego.
Stephenson PDG. Validation of iris-registration-guided femtosecond laser capsular marks to guide toric IOL alignment with intraoperative aberrometry. Presented at: American Society of Cataract and Refractive Surgery meeting; May 5-8, 2023; San Diego.
Visco D. Comparison of full sterile and nonsterile FLACS procedures in an OR environment. Presented at: CEDARS ASPENS annual meeting; Dec. 8-10, 2022; Scottsdale, Arizona.
Visco D, et al. Safety and effectiveness of a novel femtosecond laser-assisted capsular marking system for the alignment of toric IOLs. Presented at: European Society of Cataract and Refractive Surgeons meeting; Sept. 14-18, 2019; Paris.
Visco DM. Astigmatism management with arcuate incisions created with a novel, dual pulse femtosecond laser system. Presented at: American Society of Cataract and Refractive Surgery meeting; May 5-8, 2023; San Diego.
Visco DM. Iris registration-guided femtosecond laser-assisted capsular marks to guide toric IOL alignment during cataract surgery. Presented at: ASCRS ASOA annual meeting; May 3-7, 2019; San Diego.
Visco DM, et al. J Cataract Refract Surg. 2019;doi:10.1016/j.jcrs.2019.08.002.