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Thirunavukarasu AJ, Hu ML, Foster WP, Xue K, Cehajic-Kapetanovic J, MacLaren RE. Robot-Assisted Eye Surgery: A Systematic Review of Effectiveness, Safety, and Practicality in Clinical Settings. Transl Vis Sci Technol 2024; 13:20. [PMID: 38916880 PMCID: PMC11210629 DOI: 10.1167/tvst.13.6.20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 05/15/2024] [Indexed: 06/26/2024] Open
Abstract
Purpose Surgical innovation in ophthalmology is impeded by the physiological limits of human motion, and robotic assistance may facilitate an expansion of the surgical repertoire. We conducted a systematic review to identify ophthalmic procedures in which robotic systems have been trialled, evaluate their performance, and explore future directions for research and development of robotic techniques. Methods The Cochrane Library, Embase, MEDLINE, Scopus, and Web of Science were searched. Screening adhered to five criteria: (1) English language; (2) primary research article; (3) human patients; (4) ophthalmological surgery; and (5) robot-assisted surgery. Quality assessment was conducted with Joanna Briggs Institute Tools for Critical Appraisal. The study protocol was registered prospectively (PROSPERO ID CRD42023449793). Results Twelve studies were included. In comparative studies, there was no difference in the occurrence of ocular harms in robot-assisted procedures and conventional surgery. However, robotic assistance did not demonstrate consistent benefits over manual surgery in terms of effectiveness or practicality, likely reflecting the learning curve associated with these systems. Single studies indicated the potential of robotic assistance to improve the consistency of subretinal drug infusion and efficiency of instrument manipulation in vitreoretinal surgery. Conclusions Proof-of-concept studies have demonstrated the potential of robotic assistance to facilitate procedures otherwise infeasible or impractical, and may broaden access to surgery. However, robot-assisted surgery has not yet demonstrated any significant benefits over standard surgical practice. Improving the speed and reducing perioperative requirements of robot-assisted surgery are particular priorities for research and innovation to improve the practicality of these novel techniques. Translational Relevance This systematic review summarizes the potential and limitations of robotic systems for assisting eye surgery and outlines what is required for these systems to benefit patients and surgeons.
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Affiliation(s)
- Arun J Thirunavukarasu
- Nuffield Laboratory of Ophthalmology, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
- Oxford University Clinical Academic Graduate School, University of Oxford, Oxford, UK
| | - Monica L Hu
- Nuffield Laboratory of Ophthalmology, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - William P Foster
- University of Cambridge School of Clinical Medicine, University of Cambridge, Cambridge, UK
- Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, UK
| | - Kanmin Xue
- Nuffield Laboratory of Ophthalmology, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
- Oxford Eye Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Jasmina Cehajic-Kapetanovic
- Nuffield Laboratory of Ophthalmology, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
- Oxford Eye Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Robert E MacLaren
- Nuffield Laboratory of Ophthalmology, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
- Oxford Eye Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Lux F, Calikoglu A, Klusmann C, Hillenbrand M, Ataman Ç. 3D nanoprinted catadioptric fiber sensor for dual-axis distance measurement during vitrectomy. APPLIED OPTICS 2024; 63:2806-2814. [PMID: 38856375 DOI: 10.1364/ao.518950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 03/08/2024] [Indexed: 06/11/2024]
Abstract
Retinal damage is a common intraoperative complication during vitrectomy, caused by a complex interplay between the suction of the vitrectome, the cut- and aspiration rate, and the distance of the instrument to the retina. To control this last factor, we developed two miniaturized fiber-optic distance sensors based on low-coherence interferometry for direct integration into the vitrectome. Both sensors have a diameter of 250 µm, which makes them compatible with a 25G vitrectome. The first sensor measures distance in the lateral direction. The second sensor is capable of simultaneously measuring distance in both the lateral and the axial direction. Axial and lateral directions correspond to the direction of the cutter port of the vitrectome and the direction along the vitrectome's shaft, respectively. In both sensors, a free-form mirror deflects and focuses the beam in the lateral direction. In the dual-axis distance sensor, an additional lens is integrated into the free-form mirror for distance measurement in the axial direction. The beam-shaping micro-optics at the tip of the sensor fibers were fabricated through two-photon polymerization and are selectively gold coated for increased reflectivity of the mirror. Distance measurements were successfully demonstrated in artificial samples and in ex vivo pig eyes with a back-end that uses a current-tuned VCSEL as a swept-source. We experimentally demonstrate that the complete sensor system can attain a S N R max of up to 80 dB. The small dimensions of the developed sensors make them a potential solution for various other medical applications.
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Wang T, Li H, Pu T, Yang L. Microsurgery Robots: Applications, Design, and Development. SENSORS (BASEL, SWITZERLAND) 2023; 23:8503. [PMID: 37896597 PMCID: PMC10611418 DOI: 10.3390/s23208503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 10/07/2023] [Accepted: 10/09/2023] [Indexed: 10/29/2023]
Abstract
Microsurgical techniques have been widely utilized in various surgical specialties, such as ophthalmology, neurosurgery, and otolaryngology, which require intricate and precise surgical tool manipulation on a small scale. In microsurgery, operations on delicate vessels or tissues require high standards in surgeons' skills. This exceptionally high requirement in skills leads to a steep learning curve and lengthy training before the surgeons can perform microsurgical procedures with quality outcomes. The microsurgery robot (MSR), which can improve surgeons' operation skills through various functions, has received extensive research attention in the past three decades. There have been many review papers summarizing the research on MSR for specific surgical specialties. However, an in-depth review of the relevant technologies used in MSR systems is limited in the literature. This review details the technical challenges in microsurgery, and systematically summarizes the key technologies in MSR with a developmental perspective from the basic structural mechanism design, to the perception and human-machine interaction methods, and further to the ability in achieving a certain level of autonomy. By presenting and comparing the methods and technologies in this cutting-edge research, this paper aims to provide readers with a comprehensive understanding of the current state of MSR research and identify potential directions for future development in MSR.
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Affiliation(s)
- Tiexin Wang
- ZJU-UIUC Institute, International Campus, Zhejiang University, Haining 314400, China; (T.W.); (H.L.); (T.P.)
- School of Mechanical Engineering, Zhejiang University, Hangzhou 310058, China
| | - Haoyu Li
- ZJU-UIUC Institute, International Campus, Zhejiang University, Haining 314400, China; (T.W.); (H.L.); (T.P.)
| | - Tanhong Pu
- ZJU-UIUC Institute, International Campus, Zhejiang University, Haining 314400, China; (T.W.); (H.L.); (T.P.)
| | - Liangjing Yang
- ZJU-UIUC Institute, International Campus, Zhejiang University, Haining 314400, China; (T.W.); (H.L.); (T.P.)
- School of Mechanical Engineering, Zhejiang University, Hangzhou 310058, China
- Department of Mechanical Engineering, University of Illinois Urbana-Champaign, Urbana, IL 61801, USA
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Jungo A, Doorenbos L, Da Col T, Beelen M, Zinkernagel M, Márquez-Neila P, Sznitman R. Unsupervised out-of-distribution detection for safer robotically guided retinal microsurgery. Int J Comput Assist Radiol Surg 2023:10.1007/s11548-023-02909-y. [PMID: 37133678 DOI: 10.1007/s11548-023-02909-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 04/03/2023] [Indexed: 05/04/2023]
Abstract
PURPOSE A fundamental problem in designing safe machine learning systems is identifying when samples presented to a deployed model differ from those observed at training time. Detecting so-called out-of-distribution (OoD) samples is crucial in safety-critical applications such as robotically guided retinal microsurgery, where distances between the instrument and the retina are derived from sequences of 1D images that are acquired by an instrument-integrated optical coherence tomography (iiOCT) probe. METHODS This work investigates the feasibility of using an OoD detector to identify when images from the iiOCT probe are inappropriate for subsequent machine learning-based distance estimation. We show how a simple OoD detector based on the Mahalanobis distance can successfully reject corrupted samples coming from real-world ex vivo porcine eyes. RESULTS Our results demonstrate that the proposed approach can successfully detect OoD samples and help maintain the performance of the downstream task within reasonable levels. MahaAD outperformed a supervised approach trained on the same kind of corruptions and achieved the best performance in detecting OoD cases from a collection of iiOCT samples with real-world corruptions. CONCLUSION The results indicate that detecting corrupted iiOCT data through OoD detection is feasible and does not need prior knowledge of possible corruptions. Consequently, MahaAD could aid in ensuring patient safety during robotically guided microsurgery by preventing deployed prediction models from estimating distances that put the patient at risk.
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Affiliation(s)
- Alain Jungo
- ARTORG Center, University of Bern, Bern, Switzerland.
| | | | | | | | - Martin Zinkernagel
- Department of Ophthalmology and Department of Clinical Research, Bern University Hospital, Bern, Switzerland
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Iuliano L, Codenotti M. The multiprobe: a revolutionary concept for vitreoretinal surgery. Ther Adv Ophthalmol 2023; 15:25158414231173533. [PMID: 37223364 PMCID: PMC10201168 DOI: 10.1177/25158414231173533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 04/14/2023] [Indexed: 05/25/2023] Open
Affiliation(s)
| | - Marco Codenotti
- Vitreoretinal Surgery Division, Department of
Ophthalmology, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan,
Italy
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Varma S, Balaratnasingam C. Imaging and robotics: The future of epiretinal membrane management. Clin Exp Ophthalmol 2022; 50:985-987. [DOI: 10.1111/ceo.14188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2022] [Indexed: 11/12/2022]
Affiliation(s)
- Shivesh Varma
- Department of Ophthalmology Sir Charles Gairdner Hospital Nedlands Western Australia Australia
- Centre for Ophthalmology and Visual Science (incorporating Lions Eye Institute) The University of Western Australia Perth Western Australia Australia
| | - Chandrakumar Balaratnasingam
- Department of Ophthalmology Sir Charles Gairdner Hospital Nedlands Western Australia Australia
- Centre for Ophthalmology and Visual Science (incorporating Lions Eye Institute) The University of Western Australia Perth Western Australia Australia
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Ladha R, Caspers LE, Willermain F, de Smet MD. Subretinal Therapy: Technological Solutions to Surgical and Immunological Challenges. Front Med (Lausanne) 2022; 9:846782. [PMID: 35402424 PMCID: PMC8985755 DOI: 10.3389/fmed.2022.846782] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 02/21/2022] [Indexed: 12/12/2022] Open
Abstract
Recent advances in ocular gene and cellular therapy rely on precisely controlled subretinal delivery. Due to its inherent limitations, manual delivery can lead to iatrogenic damage to the retina, the retinal pigment epithelium, favor reflux into the vitreous cavity. In addition, it suffers from lack of standardization, variability in delivery and the need to maintain proficiency. With or without surgical damage, an eye challenged with an exogenous viral vector or transplanted cells will illicit an immune response. Understanding how such a response manifests itself and to what extent immune privilege protects the eye from a reaction can help in anticipating short- and long-term consequences. Avoidance of spillover from areas of immune privilege to areas which either lack or have less protection should be part of any mitigation strategy. In that regard, robotic technology can provide reproducible, standardized delivery which is not dependent on speed of injection. The advantages of microprecision medical robotic technology for precise targeted deliveries are discussed.
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Affiliation(s)
- Reza Ladha
- Departments of Ophthalmology, Centre Hospitalier Universitaire Saint-Pierre and Brugmann, Brussels, Belgium
- Université Libre de Bruxelles, Brussels, Belgium
- *Correspondence: Reza Ladha
| | - Laure E. Caspers
- Departments of Ophthalmology, Centre Hospitalier Universitaire Saint-Pierre and Brugmann, Brussels, Belgium
- Université Libre de Bruxelles, Brussels, Belgium
| | - François Willermain
- Departments of Ophthalmology, Centre Hospitalier Universitaire Saint-Pierre and Brugmann, Brussels, Belgium
- Université Libre de Bruxelles, Brussels, Belgium
| | - Marc D. de Smet
- Department of Ophthalmology, Leiden University, Leiden, Netherlands
- Preceyes B.V., Eindhoven, Netherlands
- MIOS SA, Lausanne, Switzerland
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