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MAY/JUNE 2008 I RETINA TODAY I 81

I
nnovations in ophthalmology have expanded greatly in
recent years, and we believe that the next major
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 proliferated
1
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 da Vinci Surgical System consists of two primary
components, a control console that allows the surgeon to
manipulate the robotic arms remotely (Figure 1), and the
robotic apparatus with 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 from the 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 surgeons 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 of motion,
elimination of tremor, ability to maneuver in small anatomic
spaces, and surgeon safety.
12-16
Robotic Surgery in
Ophthalmology
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
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 instruments.
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.
INSTITUTE AND GLOBAL 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 eye was achieved with the 3-D endo-
scope placed above the globe in the midline, thus mimick-
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 from the 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.
SURGI CAL 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 sutures were 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 arm were used to grasp and
remove the metallic foreign body from the 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 360 capsulorrhexis via movement
of the robotic arms.
Twenty-fivegauge 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 arm and wrist (Figure 6).
VITREORETINAL SURGERY FEATURE STORY
82 I RETINA TODAY I MAY/JUNE 2008
Figure 3. View through the consoles view-finder. Figure 4. Focused view of the robotic consoles joystick.
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.
VITREORETINAL SURGERY FEATURE STORY
MAY/JUNE 2008 I RETINA TODAY I 83
Using the robotic forceps, a 25-gauge infusion trocar
(Alcon Surgical) was placed approximately 3 mm posterior
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 3 mm
back from the limbus in the superotemporal and nasal
quadrants. A disposable 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 from the 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 from the 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 OBSERVATI ONS
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
endoscopes 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 from the 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 facilitate more delicate maneuvers
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 and minute 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 surgeons 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 of human arms. Indeed, this robot was
Figure 6. Intraocular forceps fitted with a custom bracket to
facilitate operation with the robotic arm and wrist.
Figure 7. Setting of the infusion cannula with the robotic
forceps.
Figure 8. Insertion of the modified 25-gauge vitreous cutter
and endoilluminator with the robotic arms. Left corner: low
magnification view from the robots endoscope.
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.
CONCLUSI ON
As this study demonstrated, the da Vinci robotic sys-
tem provided the needed dexterity for delicate intraocu-
lar manipulations. The da Vinci Surgical System in 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, or which
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 become more 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
emergency eye care to sites such as the battlefield or envi-
ronments with limited accessibility.
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 the Retina 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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VITREORETINAL SURGERY FEATURE STORY
84 I RETINA TODAY I MAY/JUNE 2008
Figure 9. Visualization of the stable point of rotation (remote
center).