Imagine the future of eye surgery: You’ve determined that it’s finally time to consider eye surgery. You’ve carefully researched your surgeon and the surgical technique you wish to undergo, using a consumer-friendly, third-party data analytics clearinghouse that allows easy comparison of surgical outcomes and patient satisfaction amongst different surgeons and hospitals. Your preferred surgeon is out-of-state, so you meet your surgeon by webconference.
The local telemedicine office is equipped with telepresence videoconferencing and remote-controlled examination equipment. Your eye examination is performed by your remote surgeon, using a robotically driven slit lamp microscope. You undergo a number of tests, each of which are uploaded to a secure cloud website, where the surgeon can review your results. Finally, to confirm your identity and the eye that will have surgery, an iris snapshot is taken, serving as a unique bio-identifier.
On the day of surgery, you report to your local eye surgery center, which has a state-of-the-art telerobotic workstation that will be performing delicate surgical maneuvers controlled by your surgeon located 2000 miles away. The operation consists of both pre-programmed and customized, on-the-fly steps. The former are fully automated, whereas the latter are The surgeon’s preprogrammed surgical protocol is preloaded into the workstation. To make sure that the surgery is being performed on the correct patient and correct eye, the system only gives the green light to proceed when the iris snapshot that was taken on the day of surgery matches that taken on the day of the examination. You exchange greetings with your surgeon remotely via teleconferencing and lie down under the laser workstation. A local, on-site assistant surgeon is in the room, as well as a nurse..
After numbing drops are instilled into your eye, your procedure is ready to begin. The local surgical team, including the nurse and assistant surgeon, now place their 3D glasses and view the high-definition display. They see exactly the same three-dimensional image as the surgeon located half-a-continent away. The surgeon becomes the automated surgical sequence, refined to optimize surgical outcomes and tailored as needed for the specific anatomy of your eye. The laser quickly and painlessly makes a predefined series of incisions into your eye, including ports through which the micromanipulators are then inserted. Through these ports, robotic micromanipulators are controlled by the surgeon and the surgical procedure is completed. No sutures are needed. After less than 30 minutes, you exit the procedure suite. Your procedure is a success, and your surgeon completes your examination the next day at the telemedicine office. Each time you have a visit, your data are auto-uploaded into a database that allows you to compare your results with others, and provides real-time analytics. Surgeons with the best outcomes share their techniques, resulting in continuous refinement and process improvement.
Sounds like something out of science fiction? Well, the future is closer than you might think. The majority of the processes and technology and processes described in the fictional scenario above are already here or are in development. Just this month, in the November 2014 edition of JAMA Ophthalmology, a French team of medical researchers reported the first successful use of a robotic surgical workstation to perform eye surgery in three patients. The particular operation, amniotic membrane transplantation, was chosen for its relative simplicity and lack of requirement for more intricate maneuvers required by other techniques, such as corneal transplantation. The robot arms lifted and manipulated the tissue and instruments under direct command using surgeon-controlled micromanipulators. Although the commercial robotic surgical platform used in the study was not sufficiently miniaturized to perform most types of ophthalmic surgery, the report demonstrates the exciting potential of this technique.
At the University of California, San Francisco (UCSF), eye surgeons from the UCSF Beckman Vision Center are teaming with experts from Bay Area biotechnology, engineering, and information technology firms to develop innovative integrated systems that hope to transform the practice of eye surgery. What was once and still is a skill requiring years of training that strains the limits of hand-eye coordination may one day become a computer-driven, technology-based technique that uses lasers and microinstrumentation to perform techniques with a precision not possible by human hands. Through software, the robotic platform can be constantly updated so that the latest and best surgical maneuvers are available to surgeons and their patients.
At UCSF, Dr. David Hwang and colleagues have recently installed a suite of various laser workstations that allows portions of cataract surgery, corneal transplant surgery, and LASIK vision correction surgery to be performed robotically, using a computer-driven femtosecond laser. The surgical planning is performed in software, using images from the eye and screen overlays to show where the incisions will be placed. Once activated, the execution of laser-cut incisions takes place in rapid sequence, with the entire operation completed in less than 3 minutes. Not all steps of the procedure can be performed by the laser workstation, so the surgeon must complete much of the procedure manually. But the precision of the incisions is already yielding benefits in terms of visual outcomes that are simply not possible using standard, scalpel-based techniques. Soon, a 3-D high-definition visualization system will be tested, allowing surgeons perform surgery “virtually” wearing 3D glasses. Using this technology, surgeons can view and perform surgery from a remote location.
Other researchers at UCSF have developed platforms for telemedicine examination of eye patients to examine eye patients in Thailand; nanotechnology methods of fabricating ultraminiature scalpels that can execute incisions at the micron scale (1/1000 of a millimeter); laser adaptive optics to allow visualization of single retinal cells; light-adjustable lens implants that allow dynamic “tuning” of the optical properties of a patient’s lens implant to achieve 20/20 vision without glasses; and microimplants that allow medications to be delivered for months at a time, without the need for eyedrop administration.
Dr. Hwang is working to create at UCSF a Center for Innovative Eye Surgery, the first of its kind center for developing and integrating these and other innovative technologies, to create 21st-century methods of performing eye surgery. His hope is that one day, not only will the most demanding techniques such as DMEK (Descemet’s Membrane Endothelial Keratoplasty) and DALK (Deep Anterior Lamellar Keratoplasty) be widely available to patients regardless of location or access to an expert surgeon, but that new and a yet-to-be-developed techniques will be created, advancing the state of the art in sight restoration. With persistence and luck, that vision of the future of eye surgery will be coming soon – to a telerobotic surgical workstation near you.
David G. Hwang, MD, FACS
Professor and Director, Cornea Service
University of California, San Francisco
