VISVESVARAYA TECHNOLOGICAL UNIVERSITY

“Jnana Sangama”, Belagavi-590018, Karnataka

A Technical Seminar Report on

“Robotics in Ophthalmology”

Submitted in partial fulfilment of the requirements for the award of the degree of
BACHELOR OF ENGINEERING
in
MECHANICAL ENGINEERING

Submitted by
KP SONALI 1BI19ME056

Under the Guidance of

Dr. Manjunatha MC
Associate Professor
Department of Mechanical Engineering, BIT
Bengaluru - 560004

DEPARTMENT OF MECHANICAL ENGINEERING

BANGALORE INSTITUTE OF TECHNOLOGY
K.R. Road, V.V. Pura, Bengaluru-560 004
2022-23
 VISVESVARAYA TECHNOLOGICAL UNIVERSITY
Belgavi-590018, Karnataka, India
BANGALORE INSTITUTE OF TECHNOLOGY
DEPARTMENT OF MECHANICAL ENGINEERING

CERTIFICATE

This is to certify that the Technical Seminar Report entitled “Robotics in

Ophthalmology” is a bonafide work carried out by KP Sonali (USN: 1BI19ME056),
Department of Mechanical Engineering, Bangalore Institute of Technology, Bangalore
towards the partial fulfilment of the requirements for the award of the degree Bachelor
of Engineering in Mechanical Engineering of Visvesvaraya Technological University,
Belagavi during the academic year 2022-2023. It is certified that all
corrections/suggestions indicated for internal assessment have been incorporated in the
report and deposited in Department Library. The Technical Seminar Report has been
approved as it satisfies the academic requirements in respect of Technical Seminar
Work prescribed for the said Degree.

Guide
Dr. Manjunatha MC
Associate Professor
Department of Mechanical Engineering
Bangalore Institute of
Technology Bangalore-
560004
Dr. T V Sreerama Reddy
Professor and Head
Department of Mechanical Engineering
Bangalore Institute of Technology
Bangalore-560004

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 DECLARATION

I, KP Sonali, bearing the University Seat Number IBI19ME056, of 8th semester B. E.

Mechanical Engineering, Bangalore Institute of Technology, Bengaluru, hereby declare that
the work being presented in this seminar report entitled "Robotics in Ophthalmology" is an
authentic record of the work that has been carried out by me during the course under the
supervision of Dr.Manjunatha MC, Associate Professor, Department of Mechanical
Engineering, Bangalore Institute of Technology, Bengaluru. The work contained in this report
has not been submitted in part or full to any other university or institution or professional
body for the award of any degree or diploma or fellowship.

Place: Bengaluru
Date: 28/04/2023

KP Sonali
(1BI19ME056)

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 ACKNOWLEDGEMENT

The knowledge & satisfaction that accompany the successful completion of any task would
be incomplete without mention of the people who made it possible, whose guidance and
encouragement crowned my effort with success. I would like to thank all and acknowledge
the help I have received to carry out this technical seminar.

I am most humbled to mention the enthusiastic influence provided by my Dr. Manjunatha

MC, Associate Professor, Department of Mechanical Engineering for his ideas, time-to-
time suggestions and cooperation shown during the venture and helping make my technical
seminar a success.

I would also like to thank Dr. T V Sreerama Reddy, Professor and Head of the
Department of Mechanical Engineering, Bangalore Institute of Technology, for his
constant encouragement and for making me believe in myself.

I would like to convey my sincere thanks to our college the Bangalore Institute of
Technology, Dr. Aswath M U, Principal, Bangalore Institute of Technology for being
kind enough to provide me with this opportunity.

I would also take this opportunity to thank my friends and family for their constant support
and help. I am very much pleased to express my sincere gratitude for the friendly cooperation
shown by all the staff members of the Mechanical Department, BIT.

KP Sonali (1BI19ME056)

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 ABSTRACT

Ophthalmology is a field that is now seeing the integration of robotics in its surgical
procedures and interventions. Assistance facilitated by robots offers substantial
improvements in terms of movement control, tremor cancellation, enhanced visualization,
and distance sensing. Robotic technology has only recently been integrated into
ophthalmology; hence, the progression is only in its initial stages. Robotic technologies such
as da Vinci Surgical System are integrated into the field of ophthalmology and are assisting
surgeons in complex eye surgeries. Ophthalmic surgeries require high accuracy and precision
to execute tissue manipulation, and some complex ocular surgery may take a few hours to
complete procedures that may predispose high-volume ophthalmic surgeons to work-related
musculoskeletal disorders. A complete paradigm shift has been achieved in this particular
field through the integration of advanced robotic technology, resulting in easier and more
efficient procedures. While robotic technology assists the surgeons and improves the overall
quality of care, it also projects several challenges including limited availability, training, and
the high cost of the robotic system. Although considerable studies and trials have been
conducted for various robotic systems, only a few of them have made it to the commercial
stage and ophthalmology, on its own, has a long way to go in robotics technology.

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 TABLE OF CONTENTS

Chapter 1 1
INTRODUCTION 1
1.1 Robotics 1
1.2 Robotics in Medicine 2
1.3 Ophthalmology 3
Chapter 2 4
LITERATURE REVIEW 4
2.1 Preamble 4
2.2 Literature Survey 4
Chapter 3 6
METHODOLOGY AND MATERIALS 6
3.1 Robotics in Ophthalmology 6
3.2 Robotics Model in Ophthalmic Surgery 9
3.3 Advantages of Robotics in Ophthalmology 17
3.4 Challenges of Robotics in Ophthalmology 18
Chapter 4 19
APPLICATIONS OF ROBOTICS IN OPHTHALMOLOGY 19
4.1 Corneal Laceration Repair 19
4.2 Retinal Vascular Microsurgery 19
4.3 Vitreoretinal Surgery 19
4.4 Membrane Peeling 20
4.5 Automated laser application 20
Chapter 5 21
THE SCOPE OF ROBOTICS IN OPHTHALMOLOGY 21
Chapter 6 22
CONCLUSION 22
Chapter 7 23
REFERENCES 23

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 LIST OF FIGURES

Figure 3.1 A Steady-hand Eye Robot Developed in Johns Hopkins and Intraocular Robotic
Interventional Surgical System. 6
Figure 3.2 Da Vinci Surgical System. 6
Figure 3.3 Steady-Hand Eye Robot 9
Figure 3.4 Eye Robot 1 (ER1) 9
Figure 3.5 Eye Robot 2 (ER2) 10
Figure 3.6 Applications of Johns Hopkins Steady Hand Eye Robot 11
Figure 3.7 Surgeon Console, Patient Cart and Vision Cart of a da Vinci System 14
Figure 3.8 IRISS 15

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Chapter 1
INTRODUCTION
1.1 Robotics

Word ‘ROBOT’ was introduced by Czech writer Karel Capek in his play Rossum’s Universal
Robots published in 1920. Word Robot stands for Labour. The emerging application of
Robotics in medicine and surgery is at its peak in recent times. For the last 20 years, this
system is being utilised in super specialities like urology, gastroenterology, and gynaecology
but the use of robotics in ophthalmology is still at the infant stage. New generation doctors
need to be trained well in this budding field of robotics. Robots can be of various kinds like
Surgical robots, Rehabilitation robots, Biorobots, Telepresence robots, pharmacy automation,
companion robot, and disinfection robot. Robots are mainly tele manipulators. Surgeon’s
activators are present on one end to control the “effector” on the other end.

Robotics develops machines that can substitute for humans and replicate human actions.
Robots can be used in many situations for many purposes, but today many are used in
dangerous environments (including inspection of radioactive materials, bomb
detection and deactivation), manufacturing processes, or where humans cannot. Robots can
take any form, but some are made to resemble humans in appearance. This is claimed to help
in the acceptance of robots in certain replicative behaviours which are usually performed by
people. Such robots attempt to replicate walking, lifting, speech, cognition, or any other
human activity. Many of today's robots are inspired by nature, contributing to the field of bio-
inspired robotics.

Certain robots require user input to operate while other robots function autonomously. The
research into the functionality and potential uses of robots did not grow substantially until the
20th century. Throughout history, it has been frequently assumed by various scholars,
inventors, engineers, and technicians that robots will one day be able to mimic human
behaviour and manage tasks in a human-like fashion. Today, robotics is a rapidly growing
field, as technological advances continue; researching, designing, and building new robots
serve various practical purposes, whether domestically, commercially, or militarily. Many
robots are built to do jobs that are hazardous to people, such as defusing bombs, finding
survivors in unstable ruins, and exploring mines and shipwrecks. Robotics is
also used in STEM (science, technology, engineering, and mathematics) as a teaching aid.

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1.2 Robotics in Medicine

Robotics is not a new concept in the medical field. Medical professionals have been using
robot-based applications in medicine to assist them in various ways. As the meaning denotes,
robots are essentially meant to provide labour to make the work easier for humans. Over the
past 20 years, robotics has made a place in various subspecialties of the medical world.

First developed by the Mechatronics in Medicine Laboratory, Imperial College, London,

United Kingdom, it has been almost 30 years since robots were developed for physicians’
assistance in the surgical rooms. The first robot, Probot, was designed primarily to aid the
medical team in the transurethral resection of the prostate in 1991. With technological
progression, robotics in the surgical field advanced as well and the world witnessed the
integration of robotics such as Zeus and da Vinci systems in the medical industry. These
systems have been incorporated into surgical procedures at a remarkable speed. Within the
span of 10 years, the medical industry transformed as healthcare organizations started to
utilize these systems in clinical practice.

When taken in literal terms, the robot means a machine that is designed to execute
unintelligible and repetitive tasks. However, today they are used for performing tasks that
require extreme precision, and specification, and entail certain risks and danger. The robotic
technology presently is able to perform research and tasks which cannot be possibly done
using the human workforce.

Despite the effectiveness of robotics in the field of surgery and medicine, slow progress has
been witnessed in the overall integration of technology in the health industry. They have
taken a slow route entering the field but are gaining steady advancement with the passage of
time. The telesurgical machines have been used for transcontinental robot-assisted
cholecystectomy for quite some time. Newer technology like voice-activated robotic arms has
joined the industry recently.

The introduction of robotic technology in the medical field has instigated a complete
paradigm shift. It has made the procedures easier and more efficient and has improvised the
overall quality of care. The subsequent section of the review article sheds light on how
ophthalmologists can benefit from this particular advancement.

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1.3 Ophthalmology

The word ophthalmology comes from the Greek word ophthalmos, meaning “eyeball” or
“eye.” Ophthalmology is the branch of medicine dealing with the eyes. It includes the
anatomy, physiology and diseases that may affect the eye.

Eye surgery, also known as ocular surgery, is surgery performed on the eye or its adnexa,
typically by an ophthalmologist. The eye is a very fragile organ, and requires extreme care
before, during, and after a surgical procedure to minimise or prevent further damage. An
expert eye surgeon is responsible for selecting the appropriate surgical procedure for the
patient, and for taking the necessary safety precautions. Mentions of eye surgery can be found
in several ancient texts dating back as early as 1800 BC, with cataract treatment starting in
the fifth century BC. Today it continues to be a widely practised type of surgery, with various
techniques having been developed for treating eye problems.

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Chapter 2
LITERATURE REVIEW
2.1 Preamble

The purpose of the literature review is to gain an understanding of existing research and
debate its relevance to the chosen topic. The basic purpose of the literature review is to:
Place each work in the context of its contribution to understanding the research problem
being studied, describe the relationship of each work to the others under consideration,
identify new ways to interpret prior research, and reveal any gaps that exist in the literature,
resolve conflicts amongst seemingly contradictory previous studies, identify areas of prior
scholarship to prevent duplication of effort,point the way in fulfilling a need for additional
research.

2.2 Literature Survey

2.2.1 “Robotic surgery: a current perspective” - 2004

This work aims to review the history, development, and current applications of robotics in
surgery. Several centres are currently using surgical robots and publishing data. Most of these
early studies report that robotic surgery is feasible. There is, however, a paucity of data
regarding the costs and benefits of robotics versus conventional techniques.

2.2.2 “Robotic ocular surgery” - 2006

Using a da Vinci surgical robot, ocular microsurgery was performed with the repair of a
corneal laceration in a porcine model. The experiments were performed on harvested porcine
eyes placed in an anatomical position using a foam head on a standard operating room table.
A video scope and two, 360°-rotating, 8-mm, wrested-end effector instruments were placed
over the eye with three robotic arms. The surgeon performed the actual procedures while
positioned at a robotic system console that was located across the operating room suite. Each
surgeon placed three 10-0 sutures, and this was documented with still and video photography.
Ocular microsurgery was successfully performed using the da Vinci surgical robot. The
robotic system provided excellent visualisation, as well as controlled and delicate placement
of the sutures at the corneal level.

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2.2.3 “Feasibility study of intraocular robotic surgery with the da
Vinci surgical system” - 2008
To assess the feasibility of performing intraocular robotic surgery with the da Vinci Surgical
System (Intuitive Surgical, Sunnyvale, CA). Using modified robotic instruments, 25-gauge
pars plana vitrectomy, intraocular foreign body removal, and anterior capsulorhexis was
performed with the da Vinci system on porcine eyes. The surgical system's ability was
assessed to provide the control, dexterity, manoeuvrability, and visualization necessary for
intraocular surgery. Control of the robotic wrist-like instruments allowed for the full range of
movement. The dexterity of the robotic arms was excellent, with steady instrument motion.
Visualization of the external operative field during intraocular procedures required camera
realignment, and absent retro illumination made anterior segment surgery hard to perform. In
the current design, the kinematics of the robotic arms was found to be insufficient for standard
intraocular surgery. The system's endoscope did not yield the same detail acquired by an
ophthalmic microscope.

2.2.4 “Robot-assisted intraocular surgery: development of the IRISS

and feasibility studies in an animal model” - 2013
The aim of this study is to develop a novel robotic surgical platform, the IRISS (Intraocular
Robotic Interventional and Surgical System), capable of performing both anterior and
posterior segment intraocular surgery, and to assess its performance in terms of the range of
motion, speed of motion, accuracy, and overall capacities. Intraocular procedures were
successfully performed on 16 porcine eyes. Four eyes underwent the creation of a round,
curvilinear anterior capsulorhexis without radialization. Four eyes had I/A of lens cortical
material completed without a posterior capsular tear. Four eyes completed 23-gauge PPV
followed by successful PVD induction without any complications. Finally, simulation of
microcannulation of a temporal retinal vein was successfully achieved in four eyes without
any retinal tears/perforations noted.

2.2.5 “Robotic-assisted surgery in ophthalmology” - 2018

This paper provides an overview of the current landscape of robotics in ophthalmology,
including the pros and cons of system designs, the clinical development path, and the likely
future direction of the field. Robotics is still in its infancy in ophthalmology but is rapidly
reaching a stage wherein it will be introduced into everyday ophthalmic practice. It will most
likely be introduced first for demanding vitreoretinal procedures, followed by anterior

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segment applications.

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Chapter 3
METHODOLOGY AND MATERIALS
3.1 Robotics in Ophthalmology

Figs. 1-3 illustrates some of the robotics models used in ophthalmic surgery. Although it has
become vital for all levels and all kinds of surgeries to be highly accurate and precise when it
comes to tissue manipulation, ophthalmologic surgeries are unique for their limited surgical
area and minuscule tissue structure. The delicate ocular surgical procedures are subjected to
several limitations. Factors such as hand tremors and the degree of control over the sensitive
tissue can make a huge difference.

Figure 3.1 A Steady-hand Eye Robot Developed in Johns Hopkins and Intraocular Robotic Interventional Surgical System.

Figure 3.2 Da Vinci Surgical System.

Robotic surgery in the medical field is generally implemented in the context where the
surgeon is able to operate using smart instruments that have a superior level of functions.
Mainstream clinical care has been able to improvise magnificently because of the assistance
offered through surgical robots. This technology has sufficiently offered the professionals
abilities to have

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three-dimensional views, superior instrument manoeuvrability, increased magnification, and
diminished error possibility.

As a matter of fact, ophthalmology is a medical speciality that requires stabilized hand

movement, adequate lighting, and a clear and unobstructed view. Robotic surgery is clearly
suitable for these requirements. It has curtailed the possibilities of collateral tissue damage
and threats directed toward visualization. Technically, surgeries in ophthalmology are
complicated and unlike other surgical procedures, ophthalmologists are able to work on the
surgical site and ocular structures directly. This provides them greater visibility but also
enhances the risks involved as the sensitive and delicate ocular tissue (e.g., retina) is prone to
get damaged even on the slightest error from the surgeon’s end. This challenge has been
significantly addressed through robotics technology. According to the study of Tsirbas et al.,
robotic instrumentation can offer the performing surgeon’s ability to execute a short learning
curve and improve their overall surgical speed.

Various challenges in robotics surgical systems have limited this technology’s applicability in
ophthalmology. A microsurgical robotic system for intraocular use must satisfy a few
requirements like the ease of manoeuvrability within a defined workspace, the capability to
exhibit motion of seven degrees of freedom must have a Remote Centre of Motion (RCM) or
pivot joint which must be located at entry wound, stereoscopic view, efficient separation of
sterile instrumentation from the unsterile, and compatibility with the surgical environment.
The da Vinci surgical robot has been tried for various surgeries in porcine and cadaver eyes.
Robotics has been tried for corneal perforation repair, capsulorhexis, corneal transplantation,
petrygium surgery. It has also been tried for pars plana vitrectomy and intraocular foreign
body removal. The da Vinci system includes a console for the surgeon to control, and
imaging cart and four arms attached to a mobile instrument cart. Three articulated arms of the
instrument cart carry surgical instruments while the fourth manipulates the digital
stereoscopic camera to visualize the surgical field. The multiple joints of the instruments
provide a full 360 degree of an intracorporeal movement called “EndoWrist” technology.
Tools include scissors, dissecting forceps, scalpels, spreaders and a few more. A three-
dimensional view magnified up to 12 times to 15 times is provided by the fourth arm of the
robot which has a stereoscopic camera with two light sources. Four articulated robotic arms
can be manipulated by two telemanipulation handles. A stereo viewer is an optical system
present in the surgeon’s console which provides a three-dimensional view of the operating
field. A newer version of this system has two surgeon consoles for simultaneous use with

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two operators. Thus, both surgeons can

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use the three robotic arms. Limitations of this system include high RCM which makes
intraocular movements less controllable and intra-operative visualization. These motions are
different from the movement of the surgeon’s arms with a restricted range of motion. Thus,
procedures like capsulorhexis are difficult to perform. Secondly, the video capture system
does not yield details of a sophisticated optical microscope. This results in a longer surgical
time compared to manual surgery. Newer modifications like the Si HD model are developed
solely for purpose of intraocular surgery where RCM is located near the entry wound. Also,
the Human hand is mimicked by the micro hand of the Robot. Surgeons’ accuracy increased
by 5 times to 10 times with robotic assistance. However, no system has been capable of
performing a complete ocular surgical procedure, including both anterior and posterior
intraocular surgeries. IRISS (Intraocular Robotic Interventional and Surgical System), A joint
effort of Jules Stein Eye Institute and UCLA Department of Mechanical and Aerospace
Engineering is designed to perform both anterior and posterior segment intraocular surgery. It
can be used for continuous curvilinear capsulorhexis; infusion-aspiration of the cortex, core
vitrectomy, induction of PVD along with micro cannulation of a temporal retinal vein.
Compared to da Vinci, IRISS has increased range of motion, dexterity and accuracy.
However, with the IRISS, the surgical manipulator RCM needs to be manually aligned to the
incision made in the porcine eye which takes a lot of time and energy to overcome
movements between the eye and manipulator. Clinical application of IRISS is restricted as
the patient is not under general anaesthesia and the slightest head movement can cause severe
damage. The use of Femtosecond (FS) laser in cataract and refractive surgery is also
considered to be a type of robotic system. Nagy et al first reported the use of FS lasers for
cataract surgery in 2009. The LenSx (Alcon, California, USA) was approved by FDA in
September 2009 for anterior capsulotomies in cataract surgeries. Thereafter it also got
approved for the creation of corneal incisions and fragmentation of cataracts. FS laser
systems got FDA clearance for cataract surgery in 2010. The currently available machines for
cataract surgery are LenSx, LenSar (Lensar, Inc., FL, USA), and Optimedica (Abbott
Medical Optics Inc., CA, USA) FS laser can be used to perform four groups of incisions:
capsulotomy, lens fragmentation, astigmatic relaxing incisions, and clear corneal incisions.
As laser cataract and refractive surgery has dramatically evolved towards becoming a nearly
automated process, requiring minimal intra- operative manipulation by the surgeon, future
adaptations may contribute to the inevitable shift towards automation of other anterior
segment procedures. This can be achieved by combining robotic platforms with an FS laser
device. In addition, assimilation of robotic platforms like the IRISS with intraoperative visual

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recognition technology, OCT, and laser technology could

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help facilitate the creation of a ‘no-fly zone’, whereby certain vital intraocular structures (for
example, the posterior capsule) can be delineated and restricted from instrumentation.
Robotics may be an advantage in surgeries like vitreoretinal by providing surgeon dexterity,
improving accuracy, and decreasing complications by eliminating tremors especially in
dealing with delicate fine detail manipulations.

3.2 Robotics Model in Ophthalmic Surgery

3.2.1 Johns Hopkins Steady-Hand Eye Robot

The Steady-Hand Eye Robot is a cooperatively-controlled robot assistant designed for retinal
microsurgery. Cooperative control allows the surgeon to have full control of the robot, with
his hand movements dictating exactly the movements of the robot. The robot can also be a
valuable assistant during high-risk procedures, by incorporating virtual fixtures to help
protect the patient, and by eliminating physiological tremors in the surgeon's hand during
surgery.

Figure 3.3 Steady-Hand Eye Robot

3.2.1.1 Eye Robot 1

The Eye Robot1 (ER1) is a five-degree of freedom robot, with three translational axes (x, y,
z) and two rotational axes (roll and tilt). As our initial design, it is used to develop the
understanding of ergonomic and precision requirements for eye surgery.

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Figure 3.4 Eye Robot 1 (ER1)

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Virtual RCM (vRCM) is an important cooperative-control element utilized by the ER1 to
safely position the surgical tool for retinal microsurgery. The surgeon chooses a point on the
eye, usually the insertion point of the surgical tool in the sclera of the eye, to act as the
vRCM. The motion of the tool will then be limited only to certain rotations about that one
point, helping to protect the patient and prevent possible damage to the eye.

3.2.1.2 Eye Robot 2

Eye Robot 2 (ER2) is an intermediate design for a stable and fully capable microsurgery
research platform for the evaluation and development of robot-assisted microsurgical
procedures and devices.

Figure 3.5 Eye Robot 2 (ER2)

ER2 manipulator consists of four subassemblies:

1) XYZ linear stages for translation,

2) rotary stage for rolling,
3) a tilting mechanism with a mechanical RCM, and
4) a tool adaptor with a handle force sensor.
Parker Daedal 404XR linear stages (Parker Hannifin Corp., Rohnert Park, CA) with precise
ball-screw are used to provide 100 mm travel in XYZ axes with bidirectional repeatability of
3 µm and positioning resolution of 1 µm. A Newport URS 100B rotary stage (Newport Corp.,
Irvine, CA) is used for rolling, with a resolution of 0.0005° and repeatability of 0.0001°. A
THK KR15 linear stage (THK America Inc., Schaumburg, IL) with the travel of 100 mm and
repeatability of ±3 µm is used to provide tilting motion. The last active joint is a custom-
designed RCM mechanism. A 6-DOF ATI Nano17 force/torque sensor (ATI Industrial
Automation, Apex, NC) is mounted between the RCM mechanism and the tool handle. The
end-effector has a free-spinning tool axis for holding surgical instruments.

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Here are some improvements over ER1:

 Stiffer, more precise and more responsive components.

 We increased the tool rotation range of the tilt axis to ±60° in order to cover a
variety of user ergonomic preferences and extend the functionality of the
robot for different tests and procedures.
 Mechanical RCM
 Incorporated a foot pedal for intuitive gain control.
 The new control software is based on the CISST Surgical Assistant
Workstation (SAW) modular framework that provides multithreading,
networking, data logging and standard device interfaces. It enables rapid
system prototyping by simplifying integration of new devices and smart tools
into the systems.
3.2.1.3 Applications
 Retinal Vein Cannulation

Robot-Assisted Vein Cannulation Freehand Vein Cannulation

 Retinal Peeling

Robot Peeling Robot Peeling

 Tele - Operation

Tele-Operation with the DaVinci Master Console

Figure 3.6 Applications of Johns Hopkins Steady Hand Eye Robot

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3.2.2 The da Vinci System
Robotic-assisted surgery with the daVinci Surgical System allows surgeons to perform
complex minimally invasive surgical procedures with precision and accuracy. The system is
an advanced robotic platform designed to expand the surgeon’s capabilities and offer an
option to open surgery.

The da Vinci System has been successfully used in tens of thousands of procedures. Its safety
and efficacy are documented in clinical publications and the literature supporting its use are
extensive.

The da Vinci Surgical System provides the surgeon with:

 Precision, dexterity and control during surgery

 The ability to execute 1-2 cm incisions versus longer
incisions The da Vinci Surgical System consists of:

 An ergonomically designed surgeon’s console

 A patient cart with four interactive robotic arms
 A high-performance vision System and patented EndoWrist instruments
The da Vinci system is the current standard robotic surgical system used in the field of
ophthalmology. Developed by Intuitive Surgical, USA, it is a telemanipulation robot that has
been utilized for performing pterygium surgery in human eyes and has been successful in ex
vivo corneal surgery.
This system, essentially, comprises two primary components: a control console and the
robotic apparatus. The control console is for the surgeon to manipulate the robotic arms using
the remote. The robotic apparatus comprises three, sometimes four, arms that serve the
purpose of holding a dual-channel endoscope. The console offers an ocular viewfinder that
offers a stereoscopic view of the operative field from the endoscope. The da Vinci system
allows the surgeon to manipulate the controls of the console using their fingers, wrists, hands,
and arms. These movements are then transferred to the robotic arms once they are filtered and
scaled by the computer processor. No significant delay is incurred between the movements of
the surgeon and that of the robotic arms and system.
The movements of the surgeon are almost mirrored by the system, except that the tremors and
minor movements are filtered by the processor. The system is designed in a manner that
allows the surgeon to insert, extract, roll, yaw, and grip the tools of the robot. Three arms of
the system
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carry surgical instruments, and the fourth arm, which is only recently added, manipulates the
digital stereoscopic camera to visualize the field or area under surgery. Each of the arms has
several joints, allowing the system to have a three-dimensional movement of the surgical
instruments and optics. The tools have technology that offers movement up to 360°. This is
called EndoWrist technology.
Three arms designated to operate surgical tools can handle dissecting forceps, scissors,
scalpels, spreaders, and other similar tools. The stereoscopic camera in the fourth arm
comprises a lens and dual stereoscopic cameras. The lens comprises a video imaging column
and two light sources to illuminate the field of surgery. The dual stereoscopic cameras are for
three-dimensional vision having progressive magnification, offering a magnified image up to
12-15 times.
The console in the da Vinci system has an optical viewing system, known as the stereo
viewer which offers a three-dimensional view of the operating field and showcases the
messages and icons from the system, indicating the status of the robot in real-time. There are
two telemanipulation handles that allow remote manipulation of the four articulated robotic
arms. The da Vinci SI, the updated version of the system, offers two consoles, enabling two
surgeons to operate simultaneously. However, out of the two operators, one is the primary
robotic surgeon and the other a surgical assistant. Contrary to the other newer versions, da
Vinci SI has three robotic arms instead of four and they can be utilized by two operators at
the same time.

3.2.2.1 da Vinci System in Ophthalmic Surgery

The da Vinci system can offer tremendous benefits to ocular surgical procedures, making
them more effective and convenient to proceed. The most significant property of the robotic
system is its optical magnification. The stereoscopic camera in the system offers an optical
and digital magnification of the field of surgery, enabling the surgeon to have a clear and
unobstructed view of the specific area.

Secondly, the ability of the system processor to control and filter the tremors in the surgeon’s
movements results in limiting human error and improving the quality of surgical movements.
The joints in the robotic arms enable a 360º movement which ultimately offers optimal
positioning and accuracy during the surgery. The da Vinci robot surgical system is designed
in a manner that simplifies motion. The console for the surgeons ensures better comfort
during microsurgery. To operate with minimal incisions and for conducting minimally
invasive
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surgeries, the da Vinci system offers great support by offering a magnified vision, adequate
illumination, and fine surgical movements.

The da Vinci system is the only surgical telemanipulator that is available in the market and is
currently being introduced in the field of ophthalmology for anterior and posterior segment
procedures. It can be effectively used in the procedures of corneal laceration repair, pars
plana vitrectomy, intraocular foreign body removal, anterior capsulorhexis, penetrating
keratoplasty, and pterygium surgery.

3.2.2.2 Three components of the da Vinci system

 Surgeon Console
The surgeon sits at the console, controlling the instruments while viewing the patient’s
anatomy in high-definition 3D.
 Patient Cart
Positioned alongside the bed, the patient cart holds the camera and instruments that the
surgeon controls from the console.
 Vision Cart
The vision cart makes communication between components possible and supports the
3D high-definition vision system.

Figure 3.7 Surgeon Console, Patient Cart and Vision Cart of a da Vinci System

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3.2.3 Intraocular Robotic Interventional Surgical System (IRISS)
The IRISS is a robotic surgical platform based on a master-slave manipulator design and is
dedicated to intraocular surgery. The master and slave communicate through a PXI system
(National Instruments, Austin, TX, USA) running the LabVIEW Real-Time operating system
with a sampling time of 1 ms.

Figure 3.8 IRISS

The master controller consists of two dedicated custom joysticks designed as master input
devices. The surgeon holds both shafts and manipulates them as if they were standard
intraocular surgical instruments. Motions of both shafts, measured by an optical encoder, are
transmitted to the slave to mimic their movement. The scale between the master and the slave
can be modified according to the difficulty of the task.

The slave manipulator includes two independent arms, each holding two automatically
interchangeable surgical instruments, which are both mounted to a carriage riding on a
circular track. The surgical instruments, mechanically constrained about a remote centre of
motion (RCM), or pivot point, have seven degrees of freedom (DoF) (z-direction, rotation,
and the other two axes centred at the RCM θx and θy, and cutting).

The two mechanical RCM are independent of one another and can be in close proximity (as
less as 16 mm), thus allowing for completion of ‘bimanual’ intraocular surgery. All types of
commercially available microsurgical instruments can be adapted to fit on the surgical
manipulator.

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3.2.3.1 Surgical Performances in Animal Model

To test the feasibility of performing ‘bimanual’ intraocular surgical tasks using the IRISS, we
defined four separate steps out of typical anterior (phacoemulsification) and posterior (pars
plana vitrectomy (PPV)) segment surgery. Selected phacoemulsification steps included the
construction of a continuous curvilinear capsulorhexis and cortex removal in I/A mode.
Vitrectomy steps consisted of performing a core PPV, followed by aspiration of the posterior
hyaloid with the vitreous cutter to induce a posterior vitreous detachment (PVD) assisted with
triamcinolone and simulation of the microcannulation of a temporal retinal vein. The
microcannulation task consisted of applying pressure to the wall of a 200-μm retinal temporal
vein for 30 s with a 38-gauge needle (diameter of 100 μm). Both vitreoretinal tasks involved
‘bimanual surgery,’ meaning the simultaneous use of two instruments (vitreous cutter+light
pipe and 38-gauge microcannula+light pipe). The visualization of the fundus was achieved
using a disposable flat lens (Volk, Mentor, OH, USA). For each evaluation, the duration and
the successful completion of the task with or without complications or involuntary events
were assessed.

Procedures were performed on freshly collected porcine eyes affixed to a Styrofoam

mannequin head. Given the absence of a motorized stage for both the robotic arms, the initial
alignment of the surgical manipulator’s RCM and ocular entry sites was done manually.
Tasks were performed consecutively on a total of 16 porcine eyes: 4 eyes underwent anterior
capsulorhexis, 4 eyes were subject to I/A of lens cortical material, 4 eyes underwent 3-port
23- gauge PPV followed by PVD induction, and 4 eyes were used to simulate
microcannulation of a temporal retinal vein.

The porcine eyes were slaughterhouse materials, and the Institutional Animal Care and Use
Committee of The University of UCLA approved the experimental protocol. All procedures
were performed in the Center for Advanced Surgical and Interventional Technology at the
UCLA Medical Center (Los Angeles, CA, USA). The telesurgical tasks were performed by a
trained cataract and vitreoretinal surgeon (JPH).

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3.3 Advantages of Robotics in Ophthalmology

One of the reasons why robotics technology in ophthalmology is highly anticipated is the
meticulousness achieved through it. The challenges formerly experienced in form of
movement stability are now addressed through robotics. The surgeons are able to scale both
movements and speed at the same time. This has promoted their efficiency in performing
delicate tasks.

Robotic techniques and high-precision instruments have made it achievable for

ophthalmologists to address more complex and accuracy-sensitive conditions. The robotic
systems are effective for purposes that require repetitive tasks, making the work easier for the
ophthalmologist.

Micro-incision cataract surgeries that were once deemed difficult to execute, are now
substantially aided with robotic technology such as Femtosecond lasers. These devices are
effective in performing precise corneal incision, well-sized perfect capsulorhexis, and nuclear
fragmentation and help to improve the outcome of refractive cataract surgery. The remaining
steps of phacoemulsification procedures can be performed by ophthalmic surgeons. In the
future, the robotic system can take over the tasks that involve repetitive motions, providing
the depth and strength that is ideal for the task to be carried out.

To achieve optimum results, it is important that the surgeon knows well how to operate the
robotic system. With this challenge, there are several opportunities rising as well. According
to the latest trend, surgeons are now trained on simulators. The information and steps that are
preprogrammed into the simulators and the robot make it easier for the surgeons to execute
the transition from one step to another. This makes the work easier for surgeons to perform
and in less time.

While performing invasive surgeries, the surgeons have to be careful about their posture and
movements as any unwatchful movement can cause substantial damage to the tissue. This has
limited the freedom in the movement of the surgeons and has led them to suffer from
occupational musculoskeletal disorders. Therefore, it is not just the patient's safety and
treatment that demands advancement in the surgical procedures, but the well-being of the
surgeons as well.

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3.4 Challenges of Robotics in Ophthalmology

Robotic-assisted advancement is not sans challenges. There are issues which need to be
carefully considered so that they are effectively resolved. Ophthalmological procedures need
logical processing for effective execution aside from accuracy. For an ophthalmic surgeon,
who is taking the assistance of a robotic system, he/she must be able to carry out the
procedure in a sequence of steps that are logical.

The devices utilized must be innately perceptive. For an optimally functioning robot, it is
important that it functions as a highly-skilled and proficient human being. If the device
deviates from the logical progression, it will not achieve the purpose it is designed for.

If the robotic surgical device, da Vinci, is taken into consideration, it does allow the surgeon
to achieve a magnified view of the eye and perform corneal incision but its frame rigidity
does not reciprocate the flexible movements like that of a surgeon.

We can regard da Vinci as one of the indirect devices used in ophthalmology and,
ophthalmology, on its own, has a long way to go in robotics technology. The study of Bourla,
et al., however, advocates the suitability of the da Vinci robotic system for ocular surgeries.
There are several issues highlighted in terms of levels of stress at the entry points and in
relation to the visualization of the surgical field. These issues denote that the da Vinci robotic
system is not completely appropriate as yet for ocular surgeries.

With the current and existing progression of surgical robot systems in ophthalmology, it has
become difficult to predict how robotic technology is going to proceed. The future is mostly
dependent on the clinical trial data that is to be achieved through ongoing pilot studies. Once
the relevant data is achieved, a more in-depth analysis can be conducted for the scope of
robotics in ophthalmology. Several obstacles remain before robotic surgery will become
popular in ophthalmology. A high cost, steep learning curve, and patient trust present other
challenges in robotics in ophthalmology. At present, considerable studies and trials have been
conducted for various robotic systems, only a few of them have made it to the commercial
stage and ophthalmology, on its own, has a long way to go in robotics technology.

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Chapter 4

APPLICATIONS OF ROBOTICS IN OPHTHALMOLOGY

The robots created for operating on the eyes must meet specific basic requirements. There are
three designs that are being developed currently for telemanipulators utilizing virtual or fixed
remote centre of motion, co-manipulation devices, and smart surgical tools such as a steady
hand. There are several potential applications of robotic technology in the field of
ophthalmology. Some of them are discussed underneath.

4.1 Corneal Laceration Repair

According to the study of Tsirbas et al., the da Vinci surgical system has been successfully
used in the repair of the corneal lacerations in harvested porcine eyes. The research study
compared the time taken to complete the surgery through human performance and robotic
arm performance. In the system-performed surgery, a video scope and two 360ºrotating, 8-
mm instruments with three robotic arms were positioned over the eye. The surgery was
performed using a robotic system console and was successfully executed with the advanced
visualization offered to facilitate the process and control the delicate placement of the corneal
sutures.

4.2 Retinal Vascular Microsurgery

The study of Jensen et al. presents the application of the da Vinci surgical system to perform
retinal microsurgery. In their research, they used a six degree of freedom manipulator that
required a hand-held trackball to operate. A computer controller was used to interpret the
input of the trackball and the manipulator was moved according to a pre-programmed
algorithm. The researchers claim that the device can be used in microsurgery and limit the
aspects of tremor and fatigue. The device, however, has its limitations of size and operational
features.

4.3 Vitreoretinal Surgery

The study conducted by Dogangil et al. refers to the usage of miniature autonomous robots or
microrobots. These devices are so tiny that they can fit into the barrel of a syringe and can

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execute movements like that of a submarine. Alongside, the researchers are working on
developing a three-dimensional visual serving approach that has the capability to carry

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microneedles and chemical sensors which can help in the process of surgery and diagnosis.
The objective of the research is to develop controlled magnetic fields that can steer the
microrobot, whereas an active microscope can offer real-time, three-dimensional feedback.
This can allow drug delivery in the field of vitreoretinal surgery using wireless magnetic
microrobots.

4.4 Membrane Peeling

Membrane peeling is one of the most essential and commonly performed tasks in vitreoretinal
surgery. An imperceptible increase in force or unintentional movement can lead to retinal
haemorrhages or tears that can lead to sub-optimal outcomes or prolonged surgery times.
Sunshine et al tested the micro-force sensor incorporated into a micro-pick to measure forces
generated during vitrectomy in rabbit eyes and membrane peeling in the “raw egg” and chick
chorioallantoic membrane models. They showed that there were subtle, sub-threshold
differences that separated the forces required for normal manoeuvres from those that caused
complications during surgery. Providing auditory feedback on the forces generated during a
manoeuvre can enable the surgeon to utilize this information to influence surgical
performance. When surgeons used audio feedback, the magnitude and variability of the
forces generated during membrane peeling were decreased compared to manual peeling.
Thus, the combination of the force-sensing instrument with auditory feedback provides the
potential to make membrane peeling standardized and safer, either in eyes with a typical
macular pucker or in highly myopic eyes with unusual anatomy and delicate retinal tissue.

4.5 Automated laser application

Robotic assistance in laser photocoagulation can increase efficiency and decrease error. Yang
et al tested the feasibility of automated laser photocoagulation in artificial eye models. Two
experienced retinal surgeons performed the procedure manually and with a manipulator
attached to the endolaser probe. The manipulator corrected any errors between the aiming
laser beam and the target. In the automated trials, the depth of the laser tip was maintained
within 18±2 µm root-mean-square (RMS) of its original position, while it varied in manual
trials with an error of 296±30µm RMS. They found their system to perform better than
manual or semi- automated delivery of laser photocoagulation in phantom eyes, and they aim
to develop techniques that would optimize the operation of their system in a real eye, where

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the optics are different from those in a phantom eye.

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Chapter

THE SCOPE OF ROBOTICS IN OPHTHALMOLOGY

In ophthalmology, robotics is in its initial stage but with increasing development and research
in this area, it is expected to reach a stage where it can be introduced into normal ophthalmic
practices. It can be rational to presume that there are plenty of opportunities for robotics
ophthalmic surgeries, especially in intervention performance that is only rendered possible
with robotic systems or might at least greatly simplify the existing approaches. Procedures
such as intravascular drug delivery and retinal vessel cannulation may become feasible since
robotic microsurgical manipulations would be safer with reduced iatrogenic complications.
Additionally, advanced imaging integration with robotic systems might also allow motion
guidance or total surgical procedures automation.

There are numerous potential pathways to bringing robotics into the field of ophthalmology.
Up until now, all the surgical systems enhance the time of surgery. However, there is a need
to emphasize cost and efficiency as well. The setup time can be drastically reduced by
utilizing a hybrid system implemented on current surgical tables.

Although robotic technology in ophthalmology is still in its start-up stages, the trend is
expected to follow through consistently and tremendous advancement is anticipated in the
field in the coming times. To gain a better understanding of how well robotics technology is
developing in the field, the following section offers a brief overview of the potential benefits
and challenges.

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Chapter 6

CONCLUSION
Although the field of ophthalmic robotic surgery is still in its infancy, successful
demonstrations of extraocular (corneal and scleral wounds), anterior segments (foreign body
removal and capsulorhexis), and posterior segment (25-gauge PPV) surgical tasks in animal
models validate ongoing research efforts towards making it a clinical reality. While most
surgical subspecialties have incorporated robotic platforms into routine use, ophthalmic
surgery poses a number of unique engineering challenges that have thus far limited this
technology’s applicability. A microsurgical robotic system suitable for intraocular use must
satisfy certain requirements with respect to the following:

(1) ease of manoeuvrability within a confined workspace;

(2) ability to execute motion of seven DoF;
(3) RCM, or pivot point, located at the tissue entry sites;
(4) stereoscopic visualization system;
(5) efficient assembly/disassembly of sterile instrumentation from the unsterile platform; and
(6) compatibility with the surgical environment (i.e., assimilates to patient movement).

The da Vinci surgical system was previously evaluated because of its widespread acceptance
as the premier robotic system on the market. Two design limitations, however, restrict its
practical use in ophthalmic surgery. First, having a high RCM, both located above the wrist
and at a long distance from the tip of the instrument, renders intraocular manoeuvres less
controllable and induces undue tension on the external eye surface next to the entry site.
Thus, the surgeon is required to impose a second RCM at the ocular penetration site by
moving the robotic arms appropriately. These motions are not as intuitive as the wrist
movements, do not mirror the exact movements of the surgeon’s arms, and, more
importantly, dramatically limit the range of motion. Consequently, the creation of a perfectly
round, curvilinear capsulorhexis optimal for cataract surgery has proven to be quite difficult.
Second, intraoperative visualization as ophthalmologists are accustomed to is challenging
with the da Vinci surgical system as its video capture system is designed for endoscopic use
and does not yield the detail of a sophisticated optical microscope.

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Chapter 7
REFERENCES
[1] Lanfranco A R, Castellanos AE, Desai JP, Meyers WC. “Robotic surgery: A current
perspective”. Ann Surg 2004;

[2] A Tsirbas, C Mango, E Dutson. “Robotic Occular Surgery”. Occular 2006;

[3] Bourla DH, Hubschman JP, Culjat M, Tsirbas A, Gupta A, Schwartz SD. “Feasibility
study of intraocular robotic surgery with the da Vinci surgical system”. Retina 2008;

[4] Rahimy E, Wilson J, Tsao TC, Schwartz S, Hubschman JP. “Robot-assisted intraocular
surgery: Development of the IRISS and feasibility studies in an animal model”. Eye 2013;

[5] Smet MD, Naus GJL, Faridpooya, K, Mura M. “Robotic-assisted surgery in

ophthalmology.” Curr Opin Ophthalmol 2018;

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