If effectively performed, vitreoretinal surgeons might be able to provide innovative surgical treatments to our patients with retinal arterial and venous occlusive diseases. Robotic surgery will not only cancel physiological tremor, but can also help guide surgical movement to appropriately place a microcannula tip into a retinal blood vessel and maintain it in the blood vessel in order to deliver a drug.

Due to the small size of retinal vessels, these procedures are at the physiological limitations of most vitreoretinal surgeons due to physiological tremor. The benefit of robotic surgery may be especially true for technically challenging procedures such as retinal vessel microcannulation and retinal vessel sheathotomy ( 9, 10). This result indicates that robotic assistance can enhance even the simplest surgical movements by skilled surgeons who are given objective feedback or by overcoming physiologic limitations( 8). By using robotic assistance and providing objective feedback of surgical movements, technical performance was improved by both non-ophthalmologists and accomplished surgeons. Noda et al tested the impact of robotic assistance on performance by non-ophthalmologists and skilled ophthalmologic surgeons during vitreoretinal procedures, such as accurately approaching a target on the fundus, stabilizing the instrument tip just above the fundus, and perceiving contact of the instrument tip with the fundus. Robotic surgical techniques aim to detect and actively compensate for the tremor( 7). Vitreoretinal surgeons have a physiological hand tremor with an average amplitude of 156 micrometers ( 5, 6). Robotic surgery could improve the surgical technique of the accomplished vitreoretinal surgeon who may be resistant to this innovative technology. Likewise, robotic surgery combined with using “smart” instruments that measure physiological parameters and systems that provide auditory feedback to the surgeon, can inform the surgeon of the distance of the instrument tip from the retina or the force generated during epiretinal membrane peeling, which can be used to optimize each surgical movement( 3, 4). For example, robotic surgery for all surgeons offers the possibility of placing an array of standard laser burns only to ischemic retina in a single application. While vitreoretinal surgery is obviously sophisticated and successful, surgical technique can be improved for all procedures, ranging from routine maneuvers such as laser photocoagulation or membrane peeling to those that are rarely performed because they are at the physiologic limitations of most surgeons. Some of the main technical limitations are inadequate spatial resolution and depth perception of microstructures to identify tissue planes, imprecise movements during micromanipulation of tissue due to physiological tremor, and lack of force sensing since the movements required for dissection are below the surgeon’s sensory threshold. Fine, precise motion is required to manipulate extremely delicate tissue within the small, constrained space of the eye, often with forces that are below human tactile perception( 2). Vitreoretinal surgery is one of the most technically difficult microsurgeries. In vitreoretinal surgery, there are still many challenges that must be solved in order to achieve near perfect outcomes.

Femto-second laser assisted cataract surgery gives the promise of even better outcomes( 1). The surgical time and patient recovery have been dramatically shortened, and near perfect visual outcomes are experienced almost immediately after surgery. Phacoemulsification with insertion of intra-ocular lens has revolutionized cataract surgery. Ophthalmic surgery has made huge leaps in the last few decades.

Steven d schwartz md cornea