Pneumatic tools for vitreoretinal surgery

Overcoming the impact of physiologic tremors in ophthalmology

PURPOSE

Ophthalmic surgery involves the manipulation of micron-level sized structures such as the internal limiting membrane where tactile sensation is practically absent. All humans have physiologic tremors that are of low amplitude and not discernible to the naked eye; they do not adversely affect the majority of the population's daily functioning. However, during microsurgery, such tremors can be problematic. In this review, we focus on the impact of physiological tremors on ophthalmic microsurgery and offer a comparative discussion on the impact of such tremors on other surgical specialties.

METHODS

A single investigator used the MEDLINE database (via PubMed) to search for and identify articles for inclusion in this systematic review. Ten key factors were identified as potentially having an impact on tremor amplitude: beta-blockers, muscle fatigue, robotic systems, handheld tools/micromanipulators, armrests/wrist supports, caffeine, diet, sleep deprivation, consuming alcohol, and workouts (exercise). These key terms were then searched using the advanced Boolean search tool and operators (i.e., AND, OR) available on PubMed: (*keyword*) AND (surgeon tremor OR microsurgery tremor OR hand steadiness OR simulator score).

RESULTS

Ten studies attempted to quantify the baseline severity of operator physiologic tremor. Approximately 89% of studies accessing the impact of tremors on performance in regards to surgical metrics reported an improvement in performance compared to 57% of studies concluding that tremor elimination was of benefit when considering procedural outcomes.

CONCLUSIONS

Robotic technology, new instruments, exoskeletons, technique modifications, and lifestyle factors have all demonstrated the potential to assist in overcoming tremors in ophthalmology.

The Role of Haptic Feedback in Robotic-Assisted Retinal Microsurgery Systems: A Systematic Review

Retinal microsurgery is one of the most technically difficult surgeries since it is performed at the threshold of human capability. If certain retinal conditions are left untreated, they can lead to severe damage, including irreversible blindness. Thus, techniques for reliable retinal microsurgery operations are critical. Recent research shows promise for improving surgical safety by implementing various types of sensory input and output. Sensory information is used to inform the surgeon about the environment inside the eye in real time. This review examines literature that discusses human factors and ergonomics (HFE) of sensory inputs and outputs of retinal microsurgery instrumentation with a focus on force and haptic feedback. Thirty-four studies were reviewed on the following topics: (1) variation between different input sensory devices and their performance, (2) variation between alternative output sensory devices and their performance, and (3) variation between alternative output sensory devices and their user satisfaction. This review finds that the implementation of HFE is important for the consideration of retinal microsurgery devices, but it is largely missing from current research. The addition of direct comparisons between devices, measures of user acceptance, usability evaluations, and greater realism in testing would help advance the use of haptic sensory feedback for retinal microsurgery instruments.