One Size Fits All

I stoically resist the urge to adjust my surgical mask despite each exhalation of breath partially fogging my spectacles, silently berating myself for forgetting to place tape over the bridge of my nose. The ‘one size fits all’ disposable plastic gloves I am wearing are at least a size too large, and hamper both tactile feedback and manual dexterity. Most importantly, I am conscious of maintaining my distance from anyone in close vicinity. I close my eyes and reflect on how a tricky capsulorhexis would progress in my current attire. Today, however, I am not in a surgical theatre. I am simply waiting to pay for my groceries at the local supermarket. The COVID-19 pandemic has had profound effects on all healthcare professionals, including ophthalmologists. Ancient stethoscopes have been dusted off. Old clinical knowledge revisited. Clinic and surgical set-ups adjusted. All hands on deck to help battle a new enemy. However, patients with cataracts continue to lose vision, with accompanying detrimental effects on quality of life amidst a global lockdown. In such unprecedented times, one begs the question: what if we had robots to call upon to perform cataract surgery on our patients instead? Robots to the Rescue Robot-assisted surgery has been used successfully for years in other surgical specialities including neurosurgery, general surgery and urology. Most notably, it has allowed fine-tuning of a more minimally invasive approach, thereby enabling less surgical trauma and faster post-operative recovery. In ophthalmic surgery, animal models have shown some early promise. For example, studies have shown the robot-assisted intraocular robotic interventional surgical system (IRISS) to complete successful capsulorhexis, irrigation/aspiration, and even lens extraction in animal eyes. (1,2). The dawn of robots performing cataract surgery is not a completely alien concept as it can be argued that in femtosecond laser-assisted cataract surgery (FLACS), we have already experienced somewhat of a prelude to robot-performed cataract surgery (RCS). In fact, FLACS is already marketed as a form of robotic cataract surgery in parts of the world. After 15 years of FLACS, however, the jury appears to be out, with evidence suggesting that it is not superior to conventional phacoemulsification cataract surgery and moreover, the increased associated costs do not justify its widescale use (3,4). Nonetheless, the option of FLACS certainly adds to an ophthalmologist’s surgical armamentarium, especially in selected cases. The concept of RCS does bring some potential advantages to the table. In the current climate, the need to maintain social distancing (even in clinical settings) is important in order to keep both clinicians and patients safe. RCS effectively removes the need for surgeons to be in close contact with patients and can allow an adjusted elective surgery service to resume, a notion already championed in gynaecological surgery (5). Having such robots ‘on standby’ would be a useful contingency to call upon in any future pandemics we face. The potential mainstream use of RCS can also eliminate any inter-surgeon variability in terms of performance, thereby allowing all patients to receive the same level of care. The Extinction of the Cataract Surgeon? The various surgical and patient factors in cataract surgery present several hurdles that need to be overcome during the development of a safe robotic system. Prior to starting a case, cataract surgeons plan accordingly based on the specific complexities of each case, as well as adjusting to any unexpected intraoperative challenges. Developing a robot to ‘adapt’ to the plethora of potential intraoperative difficulties will be a tall order, although recent breakthroughs in technology and engineering suggest that this is far from impossible. It is important to consider the caveat, however, that the utilisation of RCS will deskill generations of ophthalmologists. In turn, ophthalmologists will not only be less equipped to operate on the complex cases, but they will also be more ‘rusty’ in dealing with any robot-induced complications. Hence, cases for RCS may need to be carefully selected. A considerable amount of research is still required before we see the first robotic cataract surgeon. In the current milieu where a pandemic is accompanied by an impending global recession, the arrival of robots in ophthalmic theatres may be further delayed. The likely associated high costs of any future RCS will be a further deterrent to its universal use, particularly when compared with an already efficient modern-day phacoemulsification cataract surgery service (performed by humans no less!) where the majority of cases are completed as a day case. It is fair to say that when I first considered the idea of robots performing cataract surgery in place of clinicians, my initial instincts were a mixture of scepticism and an almost stubborn resistance. Fast forward several months where social distancing and a depleted medical workforce are in play during a global pandemic, it can be argued that there is indeed a place for RCS in ophthalmology. There will always be a need for the human cataract surgeon. But rather than stepping aside for artificial intelligence in the long run, we can utilise RCS judiciously to provide the best possible care for our patients. But until that day comes, we will continue to manage with our human hands. References 1. 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 (Lond) 2013;27(8):972–978. 2. Chen CW, Lee YH, Gerber MJ, Cheng H, Yang YC, Govetto A, Francone AA, Soatto S, Grundfest WS, Hubschman JP, Tsao TC. Intraocular robotic interventional surgical system (IRISS): Semi-automated OCT-guided cataract removal. Int J Med Robot. 2018 Dec;14(6):e1949. 3. Day AC, Gore DM, Bunce C, Evans JR. Laser-assisted cataract surgery versus standard ultrasound phacoemulsification cataract surgery. Cochrane Database Syst Rev. 2016 Jul 8;7:CD010735. doi: 10.1002/14651858.CD010735.pub2. 4. Schweitzer C, Brezin A, Cochener B, Monnet D, Germain C, Roseng S, Sitta R, Maillard A, Hayes N, Denis P, Pisella PJ, Benard A; FEMCAT study group. Femtosecond laser-assisted versus phacoemulsification cataract surgery (FEMCAT): a multicentre participant-masked randomised superiority and cost-effectiveness trial. Lancet. 2020 Jan 18;395(10219):212-224. 5. Kimmig R, Verheijen RHM, Rudnicki M; for SERGS Council. Robot assisted surgery during the COVID-19 pandemic, especially for gynecological cancer: a statement of the Society of European Robotic Gynaecological Surgery (SERGS). J Gynecol Oncol. 2020;31(3):e59.