The use of a robotic surgical system can provide added dexterity for delicate intraocular manipulations. By Jean Pierre Hubschman, MD; Angelo Tsirbas, MD; and Steven D. Schwartz MD

1. VITREORETINAL VITREORETINAL SURGERY FEATURE STORY SURGERY FEATURE STORY
BY JEAN PIERRE HUBSCHMAN, MD; ANGELO TSIRBAS, MD; AND STEVEN D. SCHWARTZ, MD
I
Robotic Surgery in
Ophthalmology
The use of a robotic surgical system can provide added
dexterity for delicate intraocular manipulations.
nnovations in ophthalmology have expanded greatly in
recent years, and we believe that the nextmajor
advancement in ophthalmology will be the integration
of robotic surgery. Robotic systems have been utilized in
the surgical environment for more than 15 years. Since then,
robotic surgical systems have proliferated1 in several disci-plines
such as urologic surgery,2-5 gynecologic surgery,6,7 and
cardiovascular surgery.8-10 Multiple robotic surgical systems
have been developed over the years, and the current stan-dard
is the da Vinci Surgical System(Intuitive Surgical,
Sunnyvale, CA).11
ROBOTIC SURGICAL SYSTEM
The daVinci Surgical Systemconsists of two primary
components, a control console that allows the surgeon to
manipulate the robotic arms remotely (Figure 1), and the
robotic apparatuswith three arms (or four arms in a recent
addition) that holds a dual-channel endoscope (Figure 2).
An ocular viewfinder on the console provides a stereoscopic
view of the operative field fromthe endoscope (Figure 3).
The surgeon manipulates the controls using fingers, wrists,
hands, and arms, while a computer processor filters, scales,
and relays the movements to the robotic arms and instru-ments
(Figure 4). There is no measurable delay between the
movement of the surgeon’s controls and the mirrored
movement of the robot apparatus. The processor eliminates
tremors and minor movements. The architecture of the
instruments and the da Vinci system allows the surgeon to
insert, extract, roll, pitch, yaw, and grip with the robotic
tools. The robotic arms are capable of tilt in two planes,
achieved with two “elbow” joints. The robotic arms can be
equipped with a variety of instrumentation to allow for spe-cialized
surgical procedures. Robotic surgery addresses some
of the limitations of traditional surgery, allowing the com-pletion
of advanced procedures. Advantages of robotic sur-gery
include increased precision, improved range ofmotion,
elimination of tremor, ability to maneuver in small anatomic
spaces, and surgeon safety.12-16
Figure 1. The surgeon sits comfortably at the surgical con- sole,
having a 3-D view of the surgical field and easy access to the
control handles.
Figure 2. The da Vinci robotic system has three arms. One
central arm holds the endoscope, and two side arms (green
and yellow stripes) hold surgical instrument
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2. VITREORETINAL VITREORETINAL SURGERY FEATURE STORY SURGERY FEATURE STORY
Figure 3. View through the console’s view-finder. Figure 4. Focused view of the robotic console’s joystick.
INSTITUTE ANDGLOBAL EXPERIENCE
Recently, the feasibility and applicability of robotic ocular
surgery were analyzed through a series of pioneering
studies.17-19 First-time demonstrations of external ocular sur-gery
(corneal and scleral wounds), anterior segment surgery
(foreign body removal and capsulorrhexis), and posterior
segment surgery (25-gauge vitrectomy) while utilizing the
da Vinci surgical robot have been performed at the Center
for Advanced Surgical and Interventional Technology at the
University of California, Los Angeles. All the experiments
were performed on harvested porcine eyes secured with
pins on a Styrofoam mannequin head in the anatomic posi-tion.
The head was placed on a surgical table positioned
directly under the robotic apparatus. The initial step was to
manually inflate the eye with balanced salt solution to reach
good intraocular pressure.
Visualization of the eyewas achieved with the 3-D endo-scope
placed above the globe in the midline, thusmimick-ing
the axis of standard ocular surgery using an operating
microscope. The robotic arms were placed on either side of
the globe at approximately 45° angles, resembling the
approach used by an operating surgeon. The surgical con-sole
was located approximately 15 feet fromthe surgical
table and robotic arms. Viewing the operative field via a 3-D
image and placing the hands on the master controls below
the display, the surgeon was seated comfortably. All proce-dures
were performed by an experienced retinal surgeon
with no prior practice in robotic surgery.
SURGICAL PROCEDURE
Robotic external ocular surgery was performed with
robotic arms each equipped with sterile Black Diamond
microforceps (Intuitive Surgical). Several 10-0 nylon fila-ment
sutureswere placed to close each corneal and scler-al
wound. To evaluate the feasibility of anterior-segment
robotic surgery, the tip of a 3-mm keratome held by the
robotic forceps was used to create a clear corneal incision
by manipulation of the robotic arms. Healon GV
(Advanced Medical Optics, Santa Ana, CA) was intro-duced
into the anterior chamber, and a 5.0x2.5x 0.2-mm
copper strip (Rogers Corporation, Chandler, AZ) was
placed over the lens by a human assistant. The intraocular
forceps linked to the robotic armwere used to grasp and
remove the metallic foreign body fromthe anterior cham-ber.
Healon GV was injected by the assistant to deepen
the chamber, and a cystotome held by the robotic forceps
was used to fashion a 360º capsulorrhexis viamovement
of the robotic arms.
Twenty-five–gauge robotic vitrectomy was performed
after adaptation of the commercially available intraocular
instruments for use with the robotic forceps. To allow
gripping with the robotic tools, small metal plates were
fixed to the handles of a 25-gauge vitreous cutter and
endoilluminator (Alcon Surgical, Fort Worth, TX). The
instruments were held by a magnetic stand to facilitate
easy grasping and storage (Figure 5). Intraocular forceps
were fitted with a custom bracket to facilitate operation
with the robotic armand wrist (Figure 6).
Figure 5. Metal plates were fixed to the 25-gauge instru-ments.
The instruments were held with a magnetic stand to
ease grasping and storage during surgery.
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3. VITREORETINAL VITREORETINAL SURGERY FEATURE STORY SURGERY FEATURE STORY
Figure 6. Intraocular forceps fitted with a custombracket to
facilitate operation with the robotic arm and wrist.
Figure 7. Setting of the infusion cannula with the robotic
forceps.
Using the robotic forceps, a 25-gauge infusion trocar
(Alcon Surgical) was placed approximately 3mmposterior
to the limbus in the inferotemporal quadrant. An infusion
cannula was placed in the trocar with the robotic forceps
and turned on by an assistant (Figure 7). Two additional tro-cars
were placed in a similar fashion approximately 3mm
back fromthe limbus in the superotemporal and nasal
quadrants. Adisposable wide-view vitrectomy contact lens
(Dutch Ophthalmic USA, Kingston,NH) was placed on the
cornea with viscoelastic. The vitreous cutter and endoillumi-nator
were grasped fromthe magnetic stand with the
robotic forceps and placed through the 25-gauge trocars
using the robotic arms (Figure 8).Under high-magnification
view, a core vitrectomy was performed. At the end of the
vitrectomy, the instruments were placed on the magnetic
stand and the trocars removed fromthe eye with the robot-ic
forceps. All the vitrectomy procedures were performed
with the Accurus 800CS (Alcon Surgical) fitted with a xenon
light source.
POST-SURGICAL OBSERVATIONS
Several observations were noted at the conclusion of this
study. First, visualization was a challenging aspect that will
require refinement.While the resolution of the dual-channel
endoscope’s camera was of high quality and provided excel-lent
depth perception for the external and anterior segment
steps of the ocular surgery, it did not yield the detail of an
optical microscope routinely used in intraocular surgery.
Also, the camera realignment was frequent and time-consuming.
For instance, each time an ocular instrument
was fetched fromthe magnetic stand, the endoscope had
to be tilted and zoomed out to facilitate adequate view.
Lack of an optical inversion system prevented the use of
standard wide-angle vitrectomy lenses.
Currently, the microforceps are tailored toward place-ment
of 7-0 sutures in cardiac surgery. Further miniaturiza-tion
of the forceps would facilitatemore delicatemaneuvers
and enhance grasping of smaller objects.
Control and manipulation of the ocular surgical instru-ments
was performed with relative ease by moving the tip
of the robotic forceps. For example, insertion of the instru-ments
into the globe andminute adjustments during the
vitrectomy were relatively easy tasks. Application of the tro-cars
and insertion of the vitreous cutter and endoillumina-tor
through the 25-gauge ports were smooth and swift.
Anterior capsular manipulations, however, were less accu-rate,
and a round curvilinear capsulorrhexis was not
achieved. The surgeon’s wrist movements translated almost
intuitively to instrument manipulation with no notable diffi-culties,
despite lack of prior experience with the robot.
We observed that arm movements were not as intu-itive
as wrist movements. Capable of two-plane tilt with-out
joint rotation, the robotic arms do not mirror the
exact movements ofhuman arms. Indeed, this robot was
Figure 8. Insertion of the modified 25-gauge vitreous cutter
and endoilluminator with the robotic arms. Left corner: low
magnification view from the robot’s endoscope.
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4. VITREORETINAL VITREORETINAL SURGERY FEATURE STORY SURGERY FEATURE STORY
emergency eye care to sites such as the battlefield or envi-ronments
with limited accessibility. ■
Figure 9.Visualization of the stable point of rotation (remote
center).
originally designed for laparoscopic surgery and subse-quently
was given a high (above the wrist) remote center
to avoid inadvertent tension on the skin opening during
surgery (Figure 9). This configuration was counterpro-ductive
and represented the main limitation when per-forming
intraocular surgery, in which a low stable point
of rotation is desired at the site of ocular penetration
(below the wrist) to avoid inadvertent tension on the
external eye surface. Tilting of the robotic elbow joints
resulted in unintended translation at the tips of the ocu-lar
instruments. Maneuverability of the instruments was
also limited, as the endoscope prevented positioning of
the robotic arms vertically. This limitation posed a prob-lem
during vitrectomy, rendering the outer vitreous gel
approachable only with contralateral instruments.
CONCLUSION
As this study demonstrated, the da Vinci robotic sys-tem
provided the needed dexterity for delicate intraocu-lar
manipulations. The da Vinci Surgical Systemin its cur-rent
design, however, presents two limitations for intraoc-ular
surgery. First, having a stable point of rotation above
the robotic wrist renders intraocular maneuvers less con-trollable.
Second, the endoscope-acquired images are infe-rior
to those obtained with an ophthalmic microscope, as
its dynamic range, optical resolution, and color presenta-tion
do not match the abilities of the human eye.
It is reasonable to assume that opportunities for robotics
in ophthalmic surgery lie in performing interventions
which only the robotic system renders possible, orwhich
noticeably simplify the current approach. Surgical proce-dures
that demand perfect stability and high degrees of
accuracy such as retinal vessel cannulation and
intravascu- lar drug delivery, may becomemore feasible as
robotic microsurgical manipulations can be safer with less
iatro- genic complications. In addition, integration of
advanced imaging with robotic systems may enable
guidance of motions or complete automation of surgical
procedures. Remote trans-Atlantic robotically assisted
surgery has also been demonstrated,20,21 and in the future
this may bring
Jean Pierre Hubschman, MD, is Clinical Instructor
of Ophthalmology at the Jules Stein Eye Institute in
Los Angeles. He has no financial relationships to dis-close.
Dr. Hubschman can be reached at: +1 310
206-5004; fax:+1 310 794 7905; or
hubschmanpatients@jsei.ucla.edu.
Angelo Tsirbas, MD, is Clinical Instructor of
Oculoplastics at the Jules Stein Eye Institute. He
has no financial relationships to disclose. Dr.
Tsirbas can be reached at: +1 310 206 8250; fax:
+1 310 825 9263; or oculoplastics@jsei.ucla.edu.
Steven D. Schwartz, MD, is Ahmanson Professor of
Ophthalmology, Associate Professor of
Ophthalmology, Chief of the Retina Division,
Director of the Diabetic Eye Disease and Retinal
Vascular Center, and Director of the Ophthalmic
Photography Clinical Laboratory at the Jules Stein
Eye Institute. He is also a member of theRetina Today
Editorial Board.He has no financial relationships to disclose. Dr.
Schwartz can be reached by phone: +1 310 206 7474; fax: +1
310 825 3350; or Schwartzpatients@jsei.ucla.edu.
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