Disclosures: Lindstrom reports relevant financial disclosures for Alcon, Bausch + Lomb, Minnesota Eye Consultants/Unifeye Vision Partners, Johnson & Johnson Vision and Zeiss.
April 15, 2021
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Ophthalmic robotic surgery may be most applicable in retina

Disclosures: Lindstrom reports relevant financial disclosures for Alcon, Bausch + Lomb, Minnesota Eye Consultants/Unifeye Vision Partners, Johnson & Johnson Vision and Zeiss.
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In robotic surgery, only the robotic system’s “arms” touch the patient, and the surgeon does not touch those “arms.”

Fortunately, robotic surgery still requires a surgeon, and to be direct, a very skilled one. The surgeon controls the procedure with enhanced visualization and computer assistance from a surgery command center that can be proximal or even distant from the patient.

Richard L. Lindstrom
Richard L. Lindstrom

The original goal of robotic surgery was to make major surgery less invasive, allowing procedures that required large incisions to be performed with only two small incisions. Over time, enhanced visualization was achieved for some procedures with so-called heads-up monitors, and surgeon hand movements could be geared down so that larger surgeon hand movements would move the robotic system’s instruments only millimeters and very slowly. With computer assistance, templates and procedure patterns could be programmed to potentially enhance safety and reduce damage to adjacent tissue.

The first robotic surgery was performed in 1983 at UBC Hospital in Vancouver using the Arthrobot. The first target specialty was orthopedics. The first center to use robotic surgery in the United States was Ohio State University a couple of years later. In the late 1980s, Stanford Research Institute, funded by grants from DARPA and NASA, committed significant human and financial resources to improving robotic surgery, catalyzing the amazing power of the innovation cycle in America. In 1995, the company Intuitive was founded in nearby Menlo Park, and robotic surgery was off to the races. Today, Intuitive is an $85 billion market cap company, and 8.5 million procedures have been performed on the da Vinci surgical system in 67 countries, with 6,000 systems placed globally.

Early adopters were urologists, hoping to reduce the invasiveness, blood loss and complication rate of prostate cancer management with classical suprapubic prostatectomy. Neurosurgery, cardiothoracic surgery, gastrointestinal and general surgery, spine surgery, transplant surgery, orthopedics and nearly every surgical specialty have surgeon and center advocates who have adopted robotic surgery.

Ophthalmology remains a late adopter. In my opinion, there are several reasons why this is the case. First, eye surgery is already minimally invasive with very small incisions and nearly no blood loss. Also, visualization is usually excellent. Finally, robotic systems are expensive, have a steep surgeon learning curve and usually require more time per procedure. Quality robots such as the da Vinci system cost $1 million to $2.5 million, and the per procedure costs average about $1,500 a case. That alone is a nonstarter for procedures such as cataract surgery in which facility reimbursement is lower than the typical robotic system per procedure fee. Also, for an experienced cataract surgeon, the entire procedure can be performed in less time than it takes to set up a robotic surgery system. The learning curve for robotic surgery is estimated to be between 150 and 250 procedures, and that is a daunting number for any residency program training the next generation of ophthalmic surgeons. It is also a daunting number for the practicing ophthalmic surgeon.

We in ophthalmology do, however, have a significant unmet need, and that is surgical precision, especially in retina surgery. Micron-level precision is required in several retina-vitreous procedures such as epiretinal membrane removal and especially the pioneering work in subretinal placement of pharmaceuticals, gene therapy and cell therapy/transplants. I see retina as the logical target for robotic surgery in ophthalmology. It will not be less invasive, less expensive or faster. It will potentially allow better visualization using heads-up systems with magnification, computer image enhancement, intraoperative OCT and micron-level slow-controlled maneuvers that promise greater precision.

The costs, increased procedure times and long learning curve will initially restrict ophthalmic robotic surgery to large institutions, but as vitreoretinal fellows complete training that includes robotic surgery, it will find its way into the private sector as well. I am personally challenged to see robotic surgery playing a meaningful role in anterior segment surgery, but I am open to that possibility. Without a doubt, there will be innovative surgeons and companies advancing the art and science of robotic surgery in our specialty in the decades to come.