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L'Abbate D, Prescott K, Geraghty B, Kearns VR, Steel DHW. BIOMECHANICAL CONSIDERATIONS FOR OPTIMISING SUBRETINAL INJECTIONS. Surv Ophthalmol 2024:S0039-6257(24)00053-5. [PMID: 38797394 DOI: 10.1016/j.survophthal.2024.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 05/16/2024] [Accepted: 05/20/2024] [Indexed: 05/29/2024]
Abstract
Subretinal injection is the preferred delivery technique for various novel ocular therapies and is widely used because of its precision and efficient delivery of gene and cell therapies; however, choosing an injection point and defining delivery parameters to target a specified retinal location and area is an inexact science. We provide an overview of the key factors that play important roles during subretinal injections to refine the technique, enhance patient outcomes, and minimise risks. We describe the role of anatomical and physical variables that affect subretinal bleb propagation and shape and their impact on retinal integrity. We highlight the risks associated with subretinal injections and consider strategies to mitigate reflux and retinal trauma. Finally, we explore the emerging field of robotic assistance in improving intraocular manouvrability and precision to facilitate the injection procedure.
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Affiliation(s)
- Dario L'Abbate
- Department of Eye and Vision Science, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Kia Prescott
- Department of Eye and Vision Science, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Brendan Geraghty
- Musculoskeletal and Ageing Science, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Victoria R Kearns
- Department of Eye and Vision Science, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.
| | - David H W Steel
- Department of Eye and Vision Science, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK; Sunderland Eye Infirmary, Sunderland, UK; Bioscience Institute, Newcastle University, Newcastle Upon Tyne, UK
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Kadonosono K, Inoue M, Yanagi Y. Retinal arterial and vein occlusion: is surgery ever indicated? Curr Opin Ophthalmol 2024; 35:210-216. [PMID: 38421954 DOI: 10.1097/icu.0000000000001045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
PURPOSE OF REVIEW To highlight the recent progression in surgical treatments for central retinal vein occlusion (CRVO) and central retinal artery occlusion (CRAO). RECENT FINDINGS Anti-VEGF treatment, accepted as a primary treatment for CRVO, is unable to effectively treat all types of the diseases. Regarding CRAO, there are not any accepted therapies available. There have however been recent innovations in surgery, such as utilizing robotics-assisted tools in cannulation procedures for central retinal artery occlusion, or micro-cystotomy for refractory macular edema resulting from ischemic CRVO. SUMMARY Refractory macular edema due to CRVO can be treated with aspiration of the fluid found inside the large cysts often seen in edema. The success rate of micro-cystotomy has been reported at 78% in eyes with refractory macular edema. Recent studies have shown that cannulation with tissue plasminogen activator (tPA) is effective for eyes with CRAO due to thrombus.Recent cannulation or micro-cystotomy procedures can be enhanced with the use of robotic tools which allow us to perform this difficult procedure more easily. Newly developed technology, and consequent developments in surgical procedures, will allow us to deal with unmet needs for retinal vessel occlusive diseases.
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Affiliation(s)
- Kazuaki Kadonosono
- Department of Ophthalmology and Micro-technology, Yokohama City University, School of Medicine, Yokohama, Japan
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Xu S, Hu B, Liu R, Zhao X, Sun M. Liquid-Driven Microinjection System for Precise Fundus Injection. SENSORS (BASEL, SWITZERLAND) 2024; 24:2140. [PMID: 38610350 PMCID: PMC11014097 DOI: 10.3390/s24072140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 03/19/2024] [Accepted: 03/26/2024] [Indexed: 04/14/2024]
Abstract
Microinjection is usually applied to the treatment of some retinal disorders, such as retinal vein cannulation and displaced submacular hemorrhage. Currently, the microinjection procedure is usually performed by using the viscous fluid control of a standard vitrectomy system, which applies a fixed air pressure through foot pedal activation. The injection process with the fixed pressure is uncontrollable and lacks feedback, the high flow rate of the injected drug may cause damage to the fundus tissue. In this paper, a liquid-driven microinjection system with a flow sensor is designed and developed specifically for fundus injection. In addition, a PID sliding mode control (SMC) method is proposed to achieve precise injection in the injection system. The experimental results of fundus simulation injection demonstrate that the microinjection system meets the requirements of fundus injection and reduces the impact of the injection process on the fundus tissue.
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Affiliation(s)
- Shiyu Xu
- National Key Laboratory of Intelligent Tracking and Forecasting for Infectious Diseases, Engineering Research Center of Trusted Behavior Intelligence, Ministry of Education, Tianjin Key Laboratory of Intelligent Robotics, Institute of Robotics and Automatic Information System, Nankai University, Tianjin 300350, China; (S.X.); (B.H.); (R.L.); (X.Z.)
- Institute of Intelligence Technology and Robotic Systems, Shenzhen Research Institute of Nankai University, Shenzhen 518083, China
| | - Bo Hu
- National Key Laboratory of Intelligent Tracking and Forecasting for Infectious Diseases, Engineering Research Center of Trusted Behavior Intelligence, Ministry of Education, Tianjin Key Laboratory of Intelligent Robotics, Institute of Robotics and Automatic Information System, Nankai University, Tianjin 300350, China; (S.X.); (B.H.); (R.L.); (X.Z.)
- Institute of Intelligence Technology and Robotic Systems, Shenzhen Research Institute of Nankai University, Shenzhen 518083, China
| | - Rongxin Liu
- National Key Laboratory of Intelligent Tracking and Forecasting for Infectious Diseases, Engineering Research Center of Trusted Behavior Intelligence, Ministry of Education, Tianjin Key Laboratory of Intelligent Robotics, Institute of Robotics and Automatic Information System, Nankai University, Tianjin 300350, China; (S.X.); (B.H.); (R.L.); (X.Z.)
- Institute of Intelligence Technology and Robotic Systems, Shenzhen Research Institute of Nankai University, Shenzhen 518083, China
| | - Xin Zhao
- National Key Laboratory of Intelligent Tracking and Forecasting for Infectious Diseases, Engineering Research Center of Trusted Behavior Intelligence, Ministry of Education, Tianjin Key Laboratory of Intelligent Robotics, Institute of Robotics and Automatic Information System, Nankai University, Tianjin 300350, China; (S.X.); (B.H.); (R.L.); (X.Z.)
- Institute of Intelligence Technology and Robotic Systems, Shenzhen Research Institute of Nankai University, Shenzhen 518083, China
| | - Mingzhu Sun
- National Key Laboratory of Intelligent Tracking and Forecasting for Infectious Diseases, Engineering Research Center of Trusted Behavior Intelligence, Ministry of Education, Tianjin Key Laboratory of Intelligent Robotics, Institute of Robotics and Automatic Information System, Nankai University, Tianjin 300350, China; (S.X.); (B.H.); (R.L.); (X.Z.)
- Institute of Intelligence Technology and Robotic Systems, Shenzhen Research Institute of Nankai University, Shenzhen 518083, China
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Birch J, Da Cruz L, Rhode K, Bergeles C. Trocar localisation for robot-assisted vitreoretinal surgery. Int J Comput Assist Radiol Surg 2024; 19:191-198. [PMID: 37354219 PMCID: PMC10838829 DOI: 10.1007/s11548-023-02987-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 06/12/2023] [Indexed: 06/26/2023]
Abstract
PURPOSE Robot-assisted vitreoretinal surgery provides precise and consistent operations on the back of the eye. To perform this safely, knowledge of the surgical instrument's remote centre of motion (RCM) and the location of the insertion point into the eye (trocar) is required. This enables the robot to align both positions to pivot the instrument about the trocar, thus preventing any damaging lateral forces from being exerted. METHODS Building on a system developed in previous work, this study presents a trocar localisation method that uses a micro-camera mounted on a vitreoretinal surgical forceps, to track two ArUco markers attached on either side of a trocar. The trocar position is the estimated midpoint between the markers. RESULTS Experimental evaluation of the trocar localisation was conducted. Results showed an RMSE of 1.82 mm for the localisation of the markers and an RMSE of 1.24 mm for the trocar localisation. CONCLUSIONS The proposed camera-based trocar localisation presents reasonable consistency and accuracy and shows improved results compared to other current methods. Optimum accuracy for this application would necessitate a 1.4 mm absolute error margin, which corresponds to the trocar's radius. The trocar localisation results are successfully found within this margin, yet the marker localisation would require further refinement to ensure consistency of localisation within the error margin. Further work will refine these position estimates and ensure the error stays consistently within this boundary.
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Affiliation(s)
- Jeremy Birch
- School of Biomedical Engineering and Imaging Sciences, King's College London, Strand, London, WC2R 2LS, UK.
| | - Lyndon Da Cruz
- Moorfields Eye Hospital, 162 City Rd, London, EC1V 2PD, UK
| | - Kawal Rhode
- School of Biomedical Engineering and Imaging Sciences, King's College London, Strand, London, WC2R 2LS, UK
| | - Christos Bergeles
- School of Biomedical Engineering and Imaging Sciences, King's College London, Strand, London, WC2R 2LS, UK
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Alamdar A, Usevitch DE, Wu J, Taylor RH, Gehlbach P, Iordachita I. Steady-Hand Eye Robot 3.0: Optimization and Benchtop Evaluation for Subretinal Injection. IEEE TRANSACTIONS ON MEDICAL ROBOTICS AND BIONICS 2024; 6:135-145. [PMID: 38304756 PMCID: PMC10831842 DOI: 10.1109/tmrb.2023.3336975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
Subretinal injection methods and other procedures for treating retinal conditions and diseases (many considered incurable) have been limited in scope due to limited human motor control. This study demonstrates the next generation, cooperatively controlled Steady-Hand Eye Robot (SHER 3.0), a precise and intuitive-to-use robotic platform achieving clinical standards for targeting accuracy and resolution for subretinal injections. The system design and basic kinematics are reported and a deflection model for the incorporated delta stage and validation experiments are presented. This model optimizes the delta stage parameters, maximizing the global conditioning index and minimizing torsional compliance. Five tests measuring accuracy, repeatability, and deflection show the optimized stage design achieves a tip accuracy of < 30 μm, tip repeatability of 9.3 μm and 0.02°, and deflections between 20-350 μm/N. Future work will use updated control models to refine tip positioning outcomes and will be tested on in vivo animal models.
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Affiliation(s)
- Alireza Alamdar
- Laboratory for Computational Sensing and Robotics (LCSR), Johns Hopkins University, Baltimore, MD USA
| | - David E. Usevitch
- Laboratory for Computational Sensing and Robotics (LCSR), Johns Hopkins University, Baltimore, MD USA
| | - Jiahao Wu
- Laboratory for Computational Sensing and Robotics (LCSR), Johns Hopkins University, Baltimore, MD USA
| | - Russell H. Taylor
- Laboratory for Computational Sensing and Robotics (LCSR), Johns Hopkins University, Baltimore, MD USA
| | - Peter Gehlbach
- Wilmer Eye Institute, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Iulian Iordachita
- Laboratory for Computational Sensing and Robotics (LCSR), Johns Hopkins University, Baltimore, MD USA
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Kadonosono K, Enaida H. Robotics-assisted Tools in Macular Surgery. Int Ophthalmol Clin 2024; 64:153-161. [PMID: 38146888 DOI: 10.1097/iio.0000000000000507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2023]
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Yamamoto S, Kuroki Y, Ide T, Tanaka S, Hirahara R, Takamori A, Nishimura T, Suzuma K, Kadonosono K, Enaida H. Customization of a passive surgical support robot to specifications for ophthalmic surgery and preliminary evaluation. Jpn J Ophthalmol 2023; 67:637-644. [PMID: 37561308 DOI: 10.1007/s10384-023-01017-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 07/06/2023] [Indexed: 08/11/2023]
Abstract
PURPOSE To customize a passive surgery support robot for ophthalmic surgery and preliminarily evaluate its performance. STUDY DESIGN Prospective observational study. METHODS The range of motion of the arm was analyzed during ophthalmic surgery and, based on this analysis, a commercially available passive robot was customized for surgical support for ophthalmic surgery; following which a prototype robot was constructed. To examine the effects on the brachial muscle during surgical operations with and without the prototype robot, surface electromyograms of the biceps and triceps were analyzed after performing continuous curvilinear capsulorrhexis (CCC) and suturing the sclerocorneal wound in a cataract surgery simulation. Six surgeons performed cataract surgery, and the degree of arm stability and muscle fatigue during surgery were evaluated using a visual analog scale. RESULTS During surgery, the prototype robot enabled fixation of the elbow and wrist at any position within the surgeon's range of motion, expanding the range of motion of the hand and fingers and stabilizing operability. Surface electromyography showed a significant decrease in the mean amplitude value of the biceps brachii during both CCC and suturing (p < 0.0001). No significant difference was observed in the triceps brachii. The arm stability and muscle fatigue were improved by 83.3% on the visual analog scale with the prototype robot compared with that without protpotype robot. CONCLUSION The use of a passive prototype robot may improve arm stability and reduce muscle fatigue during ophthalmic surgery.
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Affiliation(s)
- Soichiro Yamamoto
- Department of Ophthalmology, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-8501, Japan
| | - Yohei Kuroki
- Department of Ophthalmology, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-8501, Japan
| | - Toshihiro Ide
- Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Shin Tanaka
- Department of Ophthalmology and Micro-Technology, Yokohama City University, Yokohama, Japan
| | - Rintaro Hirahara
- Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Ayako Takamori
- Clinical Research Center, Saga University Hospital, Saga, Japan
| | - Tomohisa Nishimura
- Department of Ophthalmology, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-8501, Japan
- Mikawa Eye Clinic, Saga, Japan
| | - Kiyoshi Suzuma
- Department of Ophthalmology, Faculty of Medicine, Kagawa University, Takamatsu, Japan
| | - Kazuaki Kadonosono
- Department of Ophthalmology and Micro-Technology, Yokohama City University, Yokohama, Japan
| | - Hiroshi Enaida
- Department of Ophthalmology, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-8501, Japan.
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Wang T, Li H, Pu T, Yang L. Microsurgery Robots: Applications, Design, and Development. SENSORS (BASEL, SWITZERLAND) 2023; 23:8503. [PMID: 37896597 PMCID: PMC10611418 DOI: 10.3390/s23208503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 10/07/2023] [Accepted: 10/09/2023] [Indexed: 10/29/2023]
Abstract
Microsurgical techniques have been widely utilized in various surgical specialties, such as ophthalmology, neurosurgery, and otolaryngology, which require intricate and precise surgical tool manipulation on a small scale. In microsurgery, operations on delicate vessels or tissues require high standards in surgeons' skills. This exceptionally high requirement in skills leads to a steep learning curve and lengthy training before the surgeons can perform microsurgical procedures with quality outcomes. The microsurgery robot (MSR), which can improve surgeons' operation skills through various functions, has received extensive research attention in the past three decades. There have been many review papers summarizing the research on MSR for specific surgical specialties. However, an in-depth review of the relevant technologies used in MSR systems is limited in the literature. This review details the technical challenges in microsurgery, and systematically summarizes the key technologies in MSR with a developmental perspective from the basic structural mechanism design, to the perception and human-machine interaction methods, and further to the ability in achieving a certain level of autonomy. By presenting and comparing the methods and technologies in this cutting-edge research, this paper aims to provide readers with a comprehensive understanding of the current state of MSR research and identify potential directions for future development in MSR.
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Affiliation(s)
- Tiexin Wang
- ZJU-UIUC Institute, International Campus, Zhejiang University, Haining 314400, China; (T.W.); (H.L.); (T.P.)
- School of Mechanical Engineering, Zhejiang University, Hangzhou 310058, China
| | - Haoyu Li
- ZJU-UIUC Institute, International Campus, Zhejiang University, Haining 314400, China; (T.W.); (H.L.); (T.P.)
| | - Tanhong Pu
- ZJU-UIUC Institute, International Campus, Zhejiang University, Haining 314400, China; (T.W.); (H.L.); (T.P.)
| | - Liangjing Yang
- ZJU-UIUC Institute, International Campus, Zhejiang University, Haining 314400, China; (T.W.); (H.L.); (T.P.)
- School of Mechanical Engineering, Zhejiang University, Hangzhou 310058, China
- Department of Mechanical Engineering, University of Illinois Urbana-Champaign, Urbana, IL 61801, USA
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Liu W, Bai D, Kou L. Progress in central retinal artery occlusion: a narrative review. J Int Med Res 2023; 51:3000605231198388. [PMID: 37712755 PMCID: PMC10504844 DOI: 10.1177/03000605231198388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 08/14/2023] [Indexed: 09/16/2023] Open
Abstract
Central retinal artery occlusion (CRAO) is a catastrophic ophthalmic emergency that severely impairs a patient's visual function, often reducing visual acuity to counting fingers or worse. Progress in CRAO research has provided new information regarding its epidemiological characteristics and led to useful assessments through various ophthalmic examinations. Additional insights about CRAO have been gained through studies of its pathophysiological mechanisms, improving intervention timing and enhancing patient prognosis. Treatment for CRAO has evolved, particularly with assistance from surgical instruments and surgical robots. Although surgical treatment is now possible, this option is not widely recognized by ophthalmologists. Conservative therapies have limited benefits compared with the natural course of disease. Recently, pars plana vitrectomy plus endovascular surgery has received considerable interest among ophthalmologists because of its potential efficacy in the treatment of CRAO. Considering the inconsistencies in rationale and efficacy of CRAO treatment modalities, it is important to distinguish between treatment effects and the natural courses of various CRAO subclasses. This narrative review explores progress in CRAO epidemiology, pathophysiology, ophthalmic examination, and treatment.
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Affiliation(s)
- Weishai Liu
- Department of Ophthalmology, Ankang Hospital of Traditional Chinese Medicine, Ankang City, China
| | - Dan Bai
- Department of Ophthalmology, Ankang Hospital of Traditional Chinese Medicine, Ankang City, China
| | - Lieling Kou
- Department of Ophthalmology, Ankang Hospital of Traditional Chinese Medicine, Ankang City, China
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Pan-Doh N, Sikder S, Woreta FA, Handa JT. Using the language of surgery to enhance ophthalmology surgical education. Surg Open Sci 2023; 14:52-59. [PMID: 37528917 PMCID: PMC10387608 DOI: 10.1016/j.sopen.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 07/09/2023] [Indexed: 08/03/2023] Open
Abstract
Background Currently, surgical education utilizes a combination of the apprentice model, wet-lab training, and simulation, but due to reliance on subjective data, the quality of teaching and assessment can be variable. The "language of surgery," an established concept in engineering literature whose incorporation into surgical education has been limited, is defined as the description of each surgical maneuver using quantifiable metrics. This concept is different from the traditional notion of surgical language, generally thought of as the qualitative definitions and terminology used by surgeons. Methods A literature search was conducted through April 2023 using MEDLINE/PubMed using search terms to investigate wet-lab, virtual simulators, and robotics in ophthalmology, along with the language of surgery and surgical education. Articles published before 2005 were mostly excluded, although a few were included on a case-by-case basis. Results Surgical maneuvers can be quantified by leveraging technological advances in virtual simulators, video recordings, and surgical robots to create a language of surgery. By measuring and describing maneuver metrics, the learning surgeon can adjust surgical movements in an appropriately graded fashion that is based on objective and standardized data. The main contribution is outlining a structured education framework that details how surgical education could be improved by incorporating the language of surgery, using ophthalmology surgical education as an example. Conclusion By describing each surgical maneuver in quantifiable, objective, and standardized terminology, a language of surgery can be created that can be used to learn, teach, and assess surgical technical skill with an approach that minimizes bias. Key message The "language of surgery," defined as the quantification of each surgical movement's characteristics, is an established concept in the engineering literature. Using ophthalmology surgical education as an example, we describe a structured education framework based on the language of surgery to improve surgical education. Classifications Surgical education, robotic surgery, ophthalmology, education standardization, computerized assessment, simulations in teaching. Competencies Practice-Based Learning and Improvement.
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Affiliation(s)
- Nathan Pan-Doh
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Shameema Sikder
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Fasika A. Woreta
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - James T. Handa
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Li Z, Fu P, Wei BT, Wang J, Li AL, Li MJ, Bian GB. An automatic drug injection device with spatial micro-force perception guided by an microscopic image for robot-assisted ophthalmic surgery. Front Robot AI 2022; 9:913930. [PMID: 35991847 PMCID: PMC9382114 DOI: 10.3389/frobt.2022.913930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 06/30/2022] [Indexed: 11/26/2022] Open
Abstract
Retinal vein injection guided by microscopic image is an innovative procedure for treating retinal vein occlusion. However, the retina organization is complex, fine, and weak, and the operation scale and force are small. Surgeons’ limited operation and force-sensing accuracy make it difficult to perform precise and stable drug injection operations on the retina in a magnified field of image vision. In this paper, a 3-DOF automatic drug injection mechanism was designed for microscopic image guiding robot-assisted needle delivery and automatic drug injection. Additionally, the robot-assisted real-time three-dimensional micro-force-sensing method for retinal vein injection was proposed. Based on the layout of three FBG sensors on the hollow outer wall of the nested needle tube in a circular array of nickel-titanium alloys, the real-time sensing of the contact force between the intraoperative instrument and the blood vessel was realized. The experimental data of 15 groups of porcine eyeball retinal veins with diameters of 100–200 μm showed that the piercing force of surgical instruments and blood vessels is 5.95∼12.97 mN, with an average value of 9.98 mN. Furthermore, 20 groups of experimental measurements on chicken embryo blood vessels with diameters of 150–500 μm showed that the piercing force was 4.02∼23.4 mN, with an average value of 12.05 mN.
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Affiliation(s)
- Zhen Li
- School of Electronic and Information Engineering, Tongji University, Shanghai, China
- State Key Laboratory of Management and Control for Complex Systems, Institute of Automation, Chinese Academy of Sciences, Beijing, China
| | - Pan Fu
- State Key Laboratory of Management and Control for Complex Systems, Institute of Automation, Chinese Academy of Sciences, Beijing, China
- School of Automation, Beijing Information Science and Technology University, Beijing, China
| | - Bing-Ting Wei
- State Key Laboratory of Management and Control for Complex Systems, Institute of Automation, Chinese Academy of Sciences, Beijing, China
| | - Jie Wang
- State Key Laboratory of Management and Control for Complex Systems, Institute of Automation, Chinese Academy of Sciences, Beijing, China
- School of Automation, Beijing Information Science and Technology University, Beijing, China
| | - An-Long Li
- State Key Laboratory of Management and Control for Complex Systems, Institute of Automation, Chinese Academy of Sciences, Beijing, China
| | - Ming-Jun Li
- State Key Laboratory of Management and Control for Complex Systems, Institute of Automation, Chinese Academy of Sciences, Beijing, China
- School of Automation, Beijing Information Science and Technology University, Beijing, China
| | - Gui-Bin Bian
- State Key Laboratory of Management and Control for Complex Systems, Institute of Automation, Chinese Academy of Sciences, Beijing, China
- *Correspondence: Gui-Bin Bian,
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Iordachita II, de Smet MD, Naus G, Mitsuishi M, Riviere CN. Robotic Assistance for Intraocular Microsurgery: Challenges and Perspectives. PROCEEDINGS OF THE IEEE. INSTITUTE OF ELECTRICAL AND ELECTRONICS ENGINEERS 2022; 110:893-908. [PMID: 36588782 PMCID: PMC9799958 DOI: 10.1109/jproc.2022.3169466] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Intraocular surgery, one of the most challenging discipline of microsurgery, requires sensory and motor skills at the limits of human physiological capabilities combined with tremendously difficult requirements for accuracy and steadiness. Nowadays, robotics combined with advanced imaging has opened conspicuous and significant directions in advancing the field of intraocular microsurgery. Having patient treatment with greater safety and efficiency as the final goal, similar to other medical applications, robotics has a real potential to fundamentally change microsurgery by combining human strengths with computer and sensor-based technology in an information-driven environment. Still in its early stages, robotic assistance for intraocular microsurgery has been accepted with precaution in the operating room and successfully tested in a limited number of clinical trials. However, owing to its demonstrated capabilities including hand tremor reduction, haptic feedback, steadiness, enhanced dexterity, micrometer-scale accuracy, and others, microsurgery robotics has evolved as a very promising trend in advancing retinal surgery. This paper will analyze the advances in retinal robotic microsurgery, its current drawbacks and limitations, as well as the possible new directions to expand retinal microsurgery to techniques currently beyond human boundaries or infeasible without robotics.
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Affiliation(s)
- Iulian I Iordachita
- Department of Mechanical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Marc D de Smet
- Microinvasive Ocular Surgery Center (MIOS), Lausanne, Switzerland
| | | | - Mamoru Mitsuishi
- Department of Mechanical Engineering, The University of Tokyo, Japan
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Ramamurthy SR, Dave VP. Robotics in Vitreo-Retinal Surgery. Semin Ophthalmol 2022; 37:795-800. [PMID: 35576476 DOI: 10.1080/08820538.2022.2075705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE Modern vitreo-retinal surgery has scaled new frontiers with the advent of better instrumentation. However, physiological tremors, intraocular dexterity and difficulty in visualization hamper minimally invasive retinal surgery. Robotics has the potential to overcome these limitations and improve surgical outcomes. This review aims to provide a comprehensive summary of the advances made in the field of robotics in vitreo-retinal surgery. METHODS This review included 30 studies comprising randomized control trials, nonrandomized comparative studies and systematic reviews on the application of robotics in vitreo-retinal surgery. RESULTS Robotic systems presently available in vitreo-retinal surgery can be broadly classified based on the extent of automation into five categories: robot-assisted, co-manipulated, tele-operated, partially/fully automated and magnetically controlled devices. Key features of individual devices are highlighted in this review. Robotic assistance in vitreo-retinal surgery can maximize performance for routine procedures, enable high-precision procedures such as targeted gene therapy and retinal vein cannulation, improve ergonomics, and revolutionize tele-surgery. Cost limitations and compatibility with available surgical systems are the barriers in implementation of robotics in retinal microsurgery. CONCLUSION This review provides a concise summary of the available robotic systems in vitreo-retinal surgery, advantages over conventional systems, current applications and future implications. Robotics is a rapidly evolving field, which holds great promise in the future of vitreo-retinal surgery.
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Affiliation(s)
- Srishti Raksheeth Ramamurthy
- Smt. Kanuri Santhamma Center for vitreoretinal diseases, Anant Bajaj Retina Institute Kallam Anji Reddy Campus, LV Prasad Eye Institute, Hyderabad, India.,Fellow, Retina and Vitreous, Standard Chartered Academy for Eye Care Education Kallam Anji Reddy Campus, LV Prasad Eye Institute, Hyderabad, India
| | - Vivek Pravin Dave
- Smt. Kanuri Santhamma Center for vitreoretinal diseases, Anant Bajaj Retina Institute Kallam Anji Reddy Campus, LV Prasad Eye Institute, Hyderabad, India
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14
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Cehajic-Kapetanovic J, Xue K, Edwards TL, Meenink TC, Beelen MJ, Naus GJ, de Smet MD, MacLaren RE. First-in-Human Robot-Assisted Subretinal Drug Delivery Under Local Anesthesia. Am J Ophthalmol 2022; 237:104-113. [PMID: 34788592 DOI: 10.1016/j.ajo.2021.11.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 11/08/2021] [Accepted: 11/08/2021] [Indexed: 11/18/2022]
Abstract
PURPOSE To report the results of a first-in-human study using a robotic device to assist subretinal drug delivery in patients undergoing vitreoretinal surgery for macular hemorrhage. DESIGN Double-armed, randomized controlled surgical trial (ClinicalTrials.gov identifier: NCT03052881). METHODS The study was performed at the Oxford Eye Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom. In total, 12 participants were recruited-6 in the robot-assisted and 6 in the control manual surgery arm according to the prespecified inclusion and exclusion criteria. All subjects presented with acute loss of vision owing to a subfoveal hemorrhage secondary to neovascular age-related macular degeneration. After standard vitrectomy, intraoperative optical coherence tomography-guided subretinal injection of tissue plasminogen activator (TPA) was performed by either robot-assisted or conventional manual technique under local anesthesia. The robotic part of the procedure involved advancement of a cannula through the retina and stabilizing it during foot-controlled injection of up to 100 µL of TPA solution. We assessed surgical success, duration of surgery, adverse events, and tolerability of surgery under local anesthesia. RESULTS The procedure was well tolerated by all participants and safely performed in all cases. Total duration of surgery, time taken to complete the injection, and retinal microtrauma were similar between the groups and not clinically significant. Subretinal hemorrhage was successfully displaced at 1 month postintervention, except for 1 control subject, and the median gain in visual acuity was similar in both arms. CONCLUSIONS This first-in-human study demonstrates the feasibility and safety of high-precision robot-assisted subretinal drug delivery as part of the surgical management of submacular hemorrhage, simulating its potential future application in gene or cell therapy.
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Affiliation(s)
- Jasmina Cehajic-Kapetanovic
- From the Oxford Eye Hospital, Oxford University Hospitals NHS Foundation Trust (J.C.-K., K.X., T.L.E., R.E.M.), Oxford, United Kingdom; Nuffield Laboratory of Ophthalmology, University of Oxford (J.C.-K., K.X., T.L.E., R.E.M.), Oxford, United Kingdom; and Preceyes BV (T.C.M., M.J.B., G.J.N., M.D.S.), Eindhoven, the Netherlands
| | - Kanmin Xue
- From the Oxford Eye Hospital, Oxford University Hospitals NHS Foundation Trust (J.C.-K., K.X., T.L.E., R.E.M.), Oxford, United Kingdom; Nuffield Laboratory of Ophthalmology, University of Oxford (J.C.-K., K.X., T.L.E., R.E.M.), Oxford, United Kingdom; and Preceyes BV (T.C.M., M.J.B., G.J.N., M.D.S.), Eindhoven, the Netherlands
| | - Thomas L Edwards
- From the Oxford Eye Hospital, Oxford University Hospitals NHS Foundation Trust (J.C.-K., K.X., T.L.E., R.E.M.), Oxford, United Kingdom; Nuffield Laboratory of Ophthalmology, University of Oxford (J.C.-K., K.X., T.L.E., R.E.M.), Oxford, United Kingdom; and Preceyes BV (T.C.M., M.J.B., G.J.N., M.D.S.), Eindhoven, the Netherlands
| | - Thijs C Meenink
- From the Oxford Eye Hospital, Oxford University Hospitals NHS Foundation Trust (J.C.-K., K.X., T.L.E., R.E.M.), Oxford, United Kingdom; Nuffield Laboratory of Ophthalmology, University of Oxford (J.C.-K., K.X., T.L.E., R.E.M.), Oxford, United Kingdom; and Preceyes BV (T.C.M., M.J.B., G.J.N., M.D.S.), Eindhoven, the Netherlands
| | - Maarten J Beelen
- From the Oxford Eye Hospital, Oxford University Hospitals NHS Foundation Trust (J.C.-K., K.X., T.L.E., R.E.M.), Oxford, United Kingdom; Nuffield Laboratory of Ophthalmology, University of Oxford (J.C.-K., K.X., T.L.E., R.E.M.), Oxford, United Kingdom; and Preceyes BV (T.C.M., M.J.B., G.J.N., M.D.S.), Eindhoven, the Netherlands
| | - Gerrit J Naus
- From the Oxford Eye Hospital, Oxford University Hospitals NHS Foundation Trust (J.C.-K., K.X., T.L.E., R.E.M.), Oxford, United Kingdom; Nuffield Laboratory of Ophthalmology, University of Oxford (J.C.-K., K.X., T.L.E., R.E.M.), Oxford, United Kingdom; and Preceyes BV (T.C.M., M.J.B., G.J.N., M.D.S.), Eindhoven, the Netherlands
| | - Marc D de Smet
- From the Oxford Eye Hospital, Oxford University Hospitals NHS Foundation Trust (J.C.-K., K.X., T.L.E., R.E.M.), Oxford, United Kingdom; Nuffield Laboratory of Ophthalmology, University of Oxford (J.C.-K., K.X., T.L.E., R.E.M.), Oxford, United Kingdom; and Preceyes BV (T.C.M., M.J.B., G.J.N., M.D.S.), Eindhoven, the Netherlands
| | - Robert E MacLaren
- From the Oxford Eye Hospital, Oxford University Hospitals NHS Foundation Trust (J.C.-K., K.X., T.L.E., R.E.M.), Oxford, United Kingdom; Nuffield Laboratory of Ophthalmology, University of Oxford (J.C.-K., K.X., T.L.E., R.E.M.), Oxford, United Kingdom; and Preceyes BV (T.C.M., M.J.B., G.J.N., M.D.S.), Eindhoven, the Netherlands
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15
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Edwards W, Tang G, Tian Y, Draelos M, Izatt J, Kuo A, Hauser K. Data-Driven Modelling and Control for Robot Needle Insertion in Deep Anterior Lamellar Keratoplasty. IEEE Robot Autom Lett 2022; 7:1526-1533. [PMID: 37090091 PMCID: PMC10117280 DOI: 10.1109/lra.2022.3140458] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Deep anterior lamellar keratoplasty (DALK) is a technique for cornea transplantation which is associated with reduced patient morbidity. DALK has been explored as a potential application of robot microsurgery because the small scales, fine control requirements, and difficulty of visualization make it very challenging for human surgeons to perform. We address the problem of modelling the small scale interactions between the surgical tool and the cornea tissue to improve the accuracy of needle insertion, since accurate placement within 5% of target depth has been associated with more reliable clinical outcomes. We develop a data-driven autoregressive dynamic model of the tool-tissue interaction and a model predictive controller to guide robot needle insertion. In an ex vivo model, our controller significantly improves the accuracy of needle positioning by more than 40% compared to prior methods.
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Affiliation(s)
- William Edwards
- Department of Computer Science, University of Illinois at Urbana-Champaign, Urbana, IL 61801, USA
| | - Gao Tang
- Department of Computer Science, University of Illinois at Urbana-Champaign, Urbana, IL 61801, USA
| | - Yuan Tian
- Department of Biomedical Engineering, Duke University, Durham, NC 27708, USA
| | - Mark Draelos
- Department of Biomedical Engineering, Duke University, Durham, NC 27708, USA
| | - Joseph Izatt
- Department of Biomedical Engineering, Duke University, Durham, NC 27708, USA
| | - Anthony Kuo
- Department of Ophthalmology, Duke University, Durham, NC 27710, USA
| | - Kris Hauser
- Department of Computer Science, University of Illinois at Urbana-Champaign, Urbana, IL 61801, USA
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16
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Ebrahimi A, Urias MG, Patel N, Taylor RH, Gehlbach P, Iordachita I. Adaptive Control Improves Sclera Force Safety in Robot-Assisted Eye Surgery: A Clinical Study. IEEE Trans Biomed Eng 2021; 68:3356-3365. [PMID: 33822717 PMCID: PMC8492795 DOI: 10.1109/tbme.2021.3071135] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The integration of robotics into retinal microsurgery leads to a reduction in surgeon perception of tool-to-tissue interaction forces. This blunting of human tactile sensory input, which is due to the inflexible mass and large inertia of the robotic arm as compared to the milli-Newton scale of the interaction forces and fragile tissues during ophthalmic surgery, identifies a potential iatrogenic risk during robotic eye surgery. In this paper, we aim to evaluate two variants of an adaptive force control scheme implemented on the Steady-Hand Eye Robot (SHER) that are intended to mitigate the risk of unsafe scleral forces. The present study enrolled ten retina fellows and ophthalmology residents into a simulated procedure, which simply asked the trainees to follow retinal vessels in a model retina surgery environment. For this purpose, we have developed a force-sensing (equipped with Fiber Bragg Grating (FBG)) instrument to attach to the robot. A piezo-actuated linear stage for creating random lateral motions to the eyeball phantom has been provided to simulate disturbances during surgery. The SHER and all of its dependencies were set up in an operating room in the Wilmer Eye Institute at the Johns Hopkins Hospital. The clinicians conducted robot-assisted experiments with the adaptive controls incorporated as well as freehand manipulations. The results indicate that the Adaptive Norm Control (ANC) method, is able to maintain scleral forces at predetermined safe levels better than even freehand manipulations. Novice clinicians in robot training however, subjectively preferred freehand maneuvers over robotic manipulations. Clinician preferences once highly skilled with the robot is not assessed in this study.
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17
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Gerber MJ, Hubschman JP, Tsao TC. Automated Retinal Vein Cannulation on Silicone Phantoms Using Optical-Coherence-Tomography-Guided Robotic Manipulations. IEEE/ASME TRANSACTIONS ON MECHATRONICS : A JOINT PUBLICATION OF THE IEEE INDUSTRIAL ELECTRONICS SOCIETY AND THE ASME DYNAMIC SYSTEMS AND CONTROL DIVISION 2021; 26:2758-2769. [PMID: 35528629 PMCID: PMC9075181 DOI: 10.1109/tmech.2020.3045875] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Retinal vein occlusion is one of the most common causes of vision loss, occurring when a blood clot or other obstruction occludes a retinal vein. A potential remedy for retinal vein occlusion is retinal vein cannulation, a surgical procedure that involves infusing the occluded vein with a fibrinolytic drug to restore blood flow through the vascular lumen. This work presents an image-guided robotic system capable of performing automated cannulation on silicone retinal vein phantoms. The system is integrated with an optical coherence tomography probe and camera to provide visual feedback to guide the robotic system. Through automation, the developed system targets a vein phantom to within 20 μm and automatically cannulates and infuses the vascular lumen with dyed water. The system was evaluated through 30 experimental trials and shown to be capable of performing automated cannulation of retinal vein phantoms with no reported cases of failure.
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Affiliation(s)
- Matthew J Gerber
- Mechanical and Aerospace Engineering Department, University of California, Los Angeles, CA, 90095 USA
| | | | - Tsu-Chin Tsao
- Mechanical and Aerospace Engineering Department, University of California, Los Angeles, CA, 90095 USA
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18
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Alamdar A, Patel N, Urias M, Ebrahimi A, Gehlbach P, Iordachita I. Force and Velocity Based Puncture Detection in Robot Assisted Retinal Vein Cannulation: in-vivo Study. IEEE Trans Biomed Eng 2021; 69:1123-1132. [PMID: 34550878 DOI: 10.1109/tbme.2021.3114638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Retinal vein cannulation is a technically demanding surgical procedure and its feasibility may rely on using advanced surgical robots equipped with force-sensing microneedles. Reliable detection of the moment of venous puncture is important, to either alert or prevent the clinician from double puncturing the vessel and damaging the retinal surface beneath. This paper reports the first in-vivo retinal vein cannulation trial on rabbit eyes, using sensorized metal needles, and investigates puncture detection. METHODS We utilized total of four indices including two previously demonstrated ones and two new indices, based on the velocity and force of the needle tip and the correlation between the needle-tissue and tool-sclera interaction forces. We also studied the effect of detection timespan on the performance of detecting actual punctures. RESULTS The new indices, when used in conjunction with the previous algorithm, improved the detection rate form 75% to 92%, but slightly increased the number of false detections from 37 to 43. Increasing the detection window improved the detection performance, at the cost of adding to the delay. CONCLUSION The current algorithm can supplement the surgeons visual feedback and surgical judgment. To achieve automatic puncture detection, more measurements and further analysis are required. Subsequent in-vivo studies in other animals, such as pigs with their more human like eye anatomy, are required, before clinical trials. SIGNIFICANCE The study provides promising results and the criteria developed may serve as guidelines for further investigation into puncture detection in in-vivo retinal vein cannulation.
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19
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AghajaniPedram S, Ferguson P, Gerber M, Shin C, Hubschman JP, Rosen J. A Novel Tissue Identification Framework in Cataract Surgery using an Integrated Bioimpedance-Based Probe and Machine Learning Algorithms. IEEE Trans Biomed Eng 2021; 69:910-920. [PMID: 34469289 DOI: 10.1109/tbme.2021.3109246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVE The objective of this work was to develop and experimentally validate a bioimpedance-based framework to identify tissues in contact with the surgical instrument during cataract surgery. METHODS This work introduces an integrated hardware and software solution based on the unique bioimpedance of different intraocular tissues. The developed hardware can be readily integrated with commonly used surgical instruments. The proposed software framework, which encompasses data acquisition and a machine-learning classifier, is fast enough to be deployed in real-time surgical interventions. The experimental protocol included bioimpedance data collected from 31 ex vivo pig eyes targeting four intraocular tissues: Iris, Cornea, Lens, and Vitreous. RESULTS A classifier based on a support vector machine exhibited an overall accuracy of 91% across all trials. The algorithm provided substantial performance in detecting the intraocular tissues with 100% reliability and 95% sensitivity for the lens, along with 88% reliability and 94% sensitivity for the vitreous. CONCLUSION The developed impedance-based framework demonstrated successful intraocular tissue identification. SIGNIFICANCE Clinical implications include the ability to ensure safe operations by detecting posterior capsule rapture with 94% probability and improving surgical efficacy through lens detection with 100% reliability.
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20
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ROBOT-ASSISTED VITREORETINAL SURGERY IMPROVES SURGICAL ACCURACY COMPARED WITH MANUAL SURGERY: A Randomized Trial in a Simulated Setting. Retina 2021; 40:2091-2098. [PMID: 31842191 PMCID: PMC7575030 DOI: 10.1097/iae.0000000000002720] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Robot-assisted vitreoretinal surgery increases precision and limits tissue damage compared with manual surgery especially for the novice surgeon. The Eyesi Simulator is a feasible platform for investigating robot-assisted vitreoretinal surgery. Purpose: To compare manual and robot-assisted vitreoretinal surgery using a virtual-reality surgical simulator. Methods: Randomized controlled crossover study. Ten experienced vitreoretinal surgeons and 10 novice ophthalmic surgeons were included. The participants were randomized to start with either manual or robot-assisted surgery. Participants completed a test session consisting of three vitreoretinal modules on the Eyesi virtual-reality simulator. The automated metrics of performance supplied by the Eyesi simulator were used as outcome measures. Primary outcome measures were time with instruments inserted (seconds), instrument movement (mm), and tissue treatment (mm2). Results: Robot-assisted surgery was slower than manual surgery for both novices and vitreoretinal surgeons, 0.24 SD units (P = 0.024) and 0.73 SD units (P < 0.001), respectively. Robot-assisted surgery allowed for greater precision in novices and vitreoretinal surgeons, −0.96 SD units (P < 0.001) and −0.47 SD units (P < 0.001), respectively. Finally, novices using robot-assisted surgery inflicted less tissue damage when compared with that using manual surgery, −0.59 SD units (P = 0.009). Conclusion: At the cost of time, robot-assisted vitreoretinal surgery seems to improve precision and limit tissue damage compared with that of manual surgery. In particular, the performance of novice surgeons is enhanced with robot-assisted vitreoretinal surgery.
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21
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Ladha R, Meenink T, Smit J, de Smet MD. Advantages of robotic assistance over a manual approach in simulated subretinal injections and its relevance for gene therapy. Gene Ther 2021; 30:264-270. [PMID: 34002047 PMCID: PMC10113148 DOI: 10.1038/s41434-021-00262-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 04/01/2021] [Accepted: 04/22/2021] [Indexed: 11/09/2022]
Abstract
Subretinal injection is a method for gene delivery to treat genetic diseases of the photoreceptors and retinal pigment epithelium. A reflux-free subretinal injection is important to allow effective, safe, and cost-effective gene therapy to the retina. We report on a comparison between manual and robotic assistance in simulated subretinal injections using an artificial retina model. Nine surgeons carried out the procedure with and without the Preceyes Surgical System, using an OPMI Lumera 700 Zeiss surgical microscope equipped with intra-operative optical coherence tomography. Success in creating a bleb without reflux, injection duration, drift, tremor, and increase in the diameter of the puncture hole were analyzed. Robotic assistance improved drift (median 16 vs 212 µm), tremor (median 1 vs 18 µm), enlargement of the retinal hole, and allowed for prolonged injection times (median 52 vs 29 sec). Robotic assistance allowed higher rate of bleb formation (8/9 vs 4/9 attempts) with a moderate reduction in reflux (7/9 vs 8/9 attempts) in this artificial model. Robotic assistance can significantly contribute to subretinal injections and provide quantifiable parameters in assessing surgical and clinical success of novel retinal gene therapies.
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Affiliation(s)
- Reza Ladha
- Department of Ophthalmology, CHU St-Pierre and CHU Brugmann, Université Libre de Bruxelles, Bruxelles, Belgium.
| | | | | | - Marc D de Smet
- Preceyes BV, Eindhoven, the Netherlands.,Department of Ophthalmology, Leiden University, Leiden, the Netherlands.,MIOS sa, Lausanne, Switzerland
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22
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Gerber MJ, Hubschman JP, Tsao TC. Robotic posterior capsule polishing by optical coherence tomography image guidance. Int J Med Robot 2021; 17:e2248. [PMID: 33638592 DOI: 10.1002/rcs.2248] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 02/11/2021] [Accepted: 02/13/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND In cataract surgery, polishing of the posterior capsule (PC) can lead to improved surgical outcomes but is currently avoided due to its high-risk nature. This work developed a robotic system capable of performing PC polishing on ex vivo pig eyes using optical coherence tomography (OCT) guidance. METHODS The lenses of five ex vivo pig eyes were extracted and a thin layer of glue deposited onto the PC. Transpupillary OCT scans of the anterior segment were used to generate a PC-polishing trajectory. During polishing, OCT B-scans tracked the tool tip and were displayed to the operator. RESULTS Complete removal of the glue was accomplished in all five trials with no PC rupture reported. CONCLUSIONS The feasibility of using a robotic system guided by OCT to perform PC polishing on a biological model was demonstrated. Contributions include modelling of the PC anatomy, intraoperative OCT visualization, and automated tool-tip motion with scheduled aspiration pressures.
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Affiliation(s)
- Matthew J Gerber
- Stein Eye Institute, University of California, Los Angeles, Los Angeles, California, USA
| | - Jean-Pierre Hubschman
- Stein Eye Institute, University of California, Los Angeles, Los Angeles, California, USA
| | - Tsu-Chin Tsao
- Mechanical and Aerospace Engineering Department, University of California, Los Angeles, Los Angeles, California, USA
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23
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Weber S, Gavaghan K, Wimmer W, Williamson T, Gerber N, Anso J, Bell B, Feldmann A, Rathgeb C, Matulic M, Stebinger M, Schneider D, Mantokoudis G, Scheidegger O, Wagner F, Kompis M, Caversaccio M. Instrument flight to the inner ear. Sci Robot 2021; 2. [PMID: 30246168 DOI: 10.1126/scirobotics.aal4916] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Surgical robot systems can work beyond the limits of human perception, dexterity and scale making them inherently suitable for use in microsurgical procedures. However, despite extensive research, image-guided robotics applications for microsurgery have seen limited introduction into clinical care to date. Among others, challenges are geometric scale and haptic resolution at which the surgeon cannot sufficiently control a device outside the range of human faculties. Mechanisms are required to ascertain redundant control on process variables that ensure safety of the device, much like instrument-flight in avionics. Cochlear implantation surgery is a microsurgical procedure, in which specific tasks are at sub-millimetric scale and exceed reliable visuo-tactile feedback. Cochlear implantation is subject to intra- and inter-operative variations, leading to potentially inconsistent clinical and audiological outcomes for patients. The concept of robotic cochlear implantation aims to increase consistency of surgical outcomes such as preservation of residual hearing and reduce invasiveness of the procedure. We report successful image-guided, robotic CI in human. The robotic treatment model encompasses: computer-assisted surgery planning, precision stereotactic image-guidance, in-situ assessment of tissue properties and multipolar neuromonitoring (NM), all based on in vitro, in vivo and pilot data. The model is expandable to integrate additional robotic functionalities such as cochlear access and electrode insertion. Our results demonstrate the feasibility and possibilities of using robotic technology for microsurgery on the lateral skull base. It has the potential for benefit in other microsurgical domains for which there is no task-oriented, robotic technology available at present.
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Affiliation(s)
- S Weber
- ARTORG Center for Biomedical Engineering Research, University of Bern
| | - K Gavaghan
- ARTORG Center for Biomedical Engineering Research, University of Bern
| | - W Wimmer
- ARTORG Center for Biomedical Engineering Research, University of Bern.,Department of Otorhinolaryngology, Head and Neck Surgery, lnselspital, Bern University Hospital
| | - T Williamson
- ARTORG Center for Biomedical Engineering Research, University of Bern
| | - N Gerber
- ARTORG Center for Biomedical Engineering Research, University of Bern
| | - J Anso
- ARTORG Center for Biomedical Engineering Research, University of Bern
| | - B Bell
- ARTORG Center for Biomedical Engineering Research, University of Bern
| | - A Feldmann
- Institute for Surgical Technologies and Biomechanics, University of Bern
| | - C Rathgeb
- ARTORG Center for Biomedical Engineering Research, University of Bern
| | - M Matulic
- ARTORG Center for Biomedical Engineering Research, University of Bern
| | - M Stebinger
- ARTORG Center for Biomedical Engineering Research, University of Bern
| | - D Schneider
- ARTORG Center for Biomedical Engineering Research, University of Bern
| | - G Mantokoudis
- Department of Otorhinolaryngology, Head and Neck Surgery, lnselspital, Bern University Hospital
| | - O Scheidegger
- Department Neurology, Inselspital, Bern University Hospital
| | - F Wagner
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital
| | - M Kompis
- Department of Otorhinolaryngology, Head and Neck Surgery, lnselspital, Bern University Hospital
| | - M Caversaccio
- ARTORG Center for Biomedical Engineering Research, University of Bern.,Department of Otorhinolaryngology, Head and Neck Surgery, lnselspital, Bern University Hospital
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24
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Charreyron SL, Boehler Q, Danun AN, Mesot A, Becker M, Nelson BJ. A Magnetically Navigated Microcannula for Subretinal Injections. IEEE Trans Biomed Eng 2021; 68:119-129. [DOI: 10.1109/tbme.2020.2996013] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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25
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Kadonosono K, Hayashi A, de Juan E. Endovascular surgery in the field of ophthalmology. Jpn J Ophthalmol 2020; 65:1-5. [PMID: 33161486 DOI: 10.1007/s10384-020-00776-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 08/20/2020] [Indexed: 11/24/2022]
Abstract
In this article, we provide an overview of the current perspectives on endovascular surgery in ophthalmology, including a description of the various approaches, recent clinical results and future prospects. Experimental studies of endovascular surgery in ophthalmology started in the 1980s; since then, a considerable amount of research has been done to develop the procedure for clinical use. During the past two decades endovascular surgery has been performed on eyes with retinal vascular disorders, including central retinal vein occlusion and central retinal artery occlusion. The first endovascular surgery on human eyes was performed in 1998 on a patient with central retinal vein occlusion (CRVO). The most recent techniques used in retinal endovascular surgery involve manual injection of liquid agents such as tissue plasminogen activator into major retinal vessels using a 47 or 48-gauge micro-needle. New technology using a bimanual procedure and digitally assisted vitrectomy systems enables surgeons to perform this delicate procedure more effectively. Recent results reported from a number of researchers corroborate the effectiveness of the procedure. Endovascular surgery is one of the latest techniques in the field of ophthalmology and has garnered significant interest from vitreoretinal surgeons. However, it is also at the limit of what surgeons are able to accomplish with manual precision. There is still much to learn and improve to maximize the potential of this approach. The combination of skills as a surgeon, sound science, objective clinical evidence and cutting edge technology will lead to improvements in this field.
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Affiliation(s)
- Kazuaki Kadonosono
- Department of Ophthalmology and Micro-Technology, Yokohama City University, 4-57 Urafune-cho Minami-ku, Yokohama, 232-0024, Japan.
| | - Atsushi Hayashi
- Department of Ophthalmology, University of Toyama, Toyama, Japan
| | - Eugene de Juan
- Department of Ophthalmology, University of California, San Francisco, USA
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26
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Tahiri Joutei Hassani R, Sandali O, Ouadfel A, Packer M, Romano F, Thuret G, Gain P, de Smet MD, Baudouin C. [What will cataract surgery look like in the future? Alternatives in the pipeline]. J Fr Ophtalmol 2020; 43:929-943. [PMID: 32778347 DOI: 10.1016/j.jfo.2020.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/18/2020] [Accepted: 05/18/2020] [Indexed: 10/23/2022]
Abstract
Phacoemulsification is the most frequently performed surgery in the world. Over the past few years, this surgery seems to have reached a plateau with no further innovative breakthroughs. In this paper, we focus on alternatives techniques, the latest innovations, and the research and development pipeline in this field.
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Affiliation(s)
- R Tahiri Joutei Hassani
- Service de chirurgie ambulatoire, centre hospitalier d'Avranches Granville, 849, rue des Menneries, 50400 Granville, France; Centre d'ophtalmologie de Granville, Granville, France.
| | - O Sandali
- Service de chirurgie ambulatoire, clinique Guillaume-de-Varye, Bourges, France
| | - A Ouadfel
- Service de chirurgie ambulatoire, centre hospitalier d'Avranches Granville, 849, rue des Menneries, 50400 Granville, France; Centre d'ophtalmologie de Granville, Granville, France
| | - M Packer
- Mark Packer MD Consulting, Inc., Boulder, Colorado, États-Unis
| | - F Romano
- Laboratoire académique stéphanois « Biologie, Ingénierie et Imagerie de la Greffe de Cornée » (BiiGC), Saint-Étienne, France
| | - G Thuret
- Laboratoire académique stéphanois « Biologie, Ingénierie et Imagerie de la Greffe de Cornée » (BiiGC), Saint-Étienne, France; Service d'ophtalmologie du CHU Nord, université Jean-Monnet, Saint-Étienne, France
| | - P Gain
- Laboratoire académique stéphanois « Biologie, Ingénierie et Imagerie de la Greffe de Cornée » (BiiGC), Saint-Étienne, France; Service d'ophtalmologie du CHU Nord, université Jean-Monnet, Saint-Étienne, France
| | - M D de Smet
- Preceyes BV, Eindhoven, Pays-Bas; MicroInvasive Ocular Surgery Center (MIOS sa), Lausanne, Suisse
| | - C Baudouin
- Service d'ophtalmologie III, Centre hospitalier national d'ophtalmologie des Quinze-Vingts, IHU Foresight, Paris, France; Sorbonne Université, Inserm, CNRS, Institut de la vision, 17, rue Moreau, 75012 Paris, France
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Advanced robotic surgical systems in ophthalmology. Eye (Lond) 2020; 34:1554-1562. [PMID: 32152518 PMCID: PMC7608507 DOI: 10.1038/s41433-020-0837-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 02/12/2020] [Accepted: 02/26/2020] [Indexed: 12/17/2022] Open
Abstract
In this paper, an overview of advanced robotic surgical systems in ophthalmology is provided. The systems are introduced as representative examples of the degree of human vs. robotic control during surgical procedures. The details are presented on each system and the latest advancements of each are described. Future potential applications for surgical robotics in ophthalmology are discussed in detail, with representative examples provided alongside recent progress.
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A comparison of robotic and manual surgery for internal limiting membrane peeling. Graefes Arch Clin Exp Ophthalmol 2020; 258:773-778. [DOI: 10.1007/s00417-020-04613-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 01/17/2020] [Accepted: 01/27/2020] [Indexed: 12/11/2022] Open
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Real Time Prediction of Sclera Force with LSTM Neural Networks in Robot-Assisted Retinal Surgery. ACTA ACUST UNITED AC 2020; 896:183-194. [PMID: 34532719 DOI: 10.4028/www.scientific.net/amm.896.183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Retinal microsurgery is one of the most technically demanding surgeries, during which the surgical tool needs to be inserted into the eyeball and is constantly constrained by the sclerotomy port. During the surgery, any unexpected manipulation could cause extreme tool-sclera contact force leading to sclera damage. Although, a robot assistant could reduce hand tremor and improve the tool positioning accuracy, it cannot prevent or alarm the surgeon about the upcoming danger caused by surgeon's misoperations, i.e., applying excessive force on the sclera. In this paper, we present a new method based on a Long Short Term Memory recurrent neural network for predicting the user behavior, i.e., the contact force between the tool and sclera (sclera force) and the insertion depth of the tool from sclera contact point (insertion depth) in real time (40Hz). The predicted force information is provided to the user through auditory feedback to alarm any unexpected sclera force. The user behavior data is collected in a mock retinal surgical operation on a dry eye phantom with Steady Hand Eye Robot and a novel multi-function sensing tool. The Long Short Term Memory recurrent neural network is trained on the collected time series of sclera force and insertion depth. The network can predict the sclera force and insertion depth 100 milliseconds in the future with 95.29% and 96.57% accuracy, respectively, and can help reduce the fraction of unsafe sclera forces from 40.19% to 15.43%.
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Smet MD, Jonge N, Iannetta D, Faridpooya K, Oosterhout E, Naus G, Meenink TC, Mura M, Beelen MJ. Human/robotic interaction: vision limits performance in simulated vitreoretinal surgery. Acta Ophthalmol 2019; 97:672-678. [PMID: 30588753 DOI: 10.1111/aos.14003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 11/21/2018] [Indexed: 01/09/2023]
Abstract
PURPOSE Compare accuracy and precision in XYZ of stationary and dynamic tasks performed by surgeons with and without the use of a tele-operated robotic micromanipulator in a simulated vitreoretinal environment. The tasks were performed using a surgical microscope or while observing a video monitor. METHOD Two experienced and two novice surgeons performed tracking and static tasks at a fixed depth with hand-held instruments on a Preceyes Surgical System R0.4. Visualization was through a standard microscope or a video display. The distances between the instrument tip and the targets (in μm) determined tracking errors in accuracy and precision. RESULTS Using a microscope, dynamic or static accuracy and precision in XY (planar) movements were similar among test subjects. In Z (depth) movements, experience lead to more precision in both dynamic and static tasks (dynamic 35 ± 14 versus 60 ± 37 μm; static 27 ± 8 versus 36 ± 10 μm), and more accuracy in dynamic tasks (58 ± 35 versus 109 ± 79 μm). Robotic assistance improved both precision and accuracy in Z (1-3 ± 1 μm) in both groups. Using a video screen in combination with robotic assistance improved all performance measurements and reduced any differences due to experience. CONCLUSIONS Robotics increases precision and accuracy, with greater benefit observed in less experienced surgeons. However, human control was a limiting factor in the achieved improvement. A major limitation was visualization of the target surface, in particular in depth. To maximize the benefit of robotic assistance, visualization must be optimized.
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Affiliation(s)
- Marc D. Smet
- Microinvasive Ocular Surgery Center (MIOS sa) Lausanne Switzerland
- Preceyes BV Eindhoven the Netherlands
| | | | - Danilo Iannetta
- Royal Liverpool University Hospital St Paul's Eye Unit Liverpool UK
- Department of Clinical Sciences and Translational Medicine University of Tor Vergata Rome Italy
| | | | | | | | | | - Marco Mura
- Faculty of Medicine Johns Hopkins University Baltimore MD USA
- King Khaled Specialist Eye Hospital Riyadh Saudi Arabia
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31
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He C, Patel N, Iordachita I, Kobilarov M. Enabling Technology for Safe Robot-Assisted Retinal Surgery: Early Warning for Unsafe Scleral Force. IEEE INTERNATIONAL CONFERENCE ON ROBOTICS AND AUTOMATION : ICRA : [PROCEEDINGS]. IEEE INTERNATIONAL CONFERENCE ON ROBOTICS AND AUTOMATION 2019; 2019:3889-3894. [PMID: 32368361 DOI: 10.1109/icra.2019.8794427] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Retinal microsurgery is technically demanding and requires high surgical skill with very little room for manipulation error. During surgery the tool needs to be inserted into the eyeball while maintaining constant contact with the sclera. Any unexpected manipulation could cause extreme tool-sclera contact force (scleral force) thus damage the sclera. The introduction of robotic assistance could enhance and expand the surgeon's manipulation capabilities during surgery. However, the potential intra-operative danger from surgeon's misoperations remains difficult to detect and prevent by existing robotic systems. Therefore, we propose a method to predict imminent unsafe manipulation in robot-assisted retinal surgery and generate feedback to the surgeon via auditory substitution. The surgeon could then react to the possible unsafe events in advance. This work specifically focuses on minimizing sclera damage using a force-sensing tool calibrated to measure small scleral forces. A recurrent neural network is designed and trained to predict the force safety status up to 500 milliseconds in the future. The system is implemented using an existing "steady hand" eye robot. A vessel following manipulation task is designed and performed on a dry eye phantom to emulate the retinal surgery and to analyze the proposed method. Finally, preliminary validation experiments are performed by five users, the results of which indicate that the proposed early warning system could help to reduce the number of unsafe manipulation events.
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Affiliation(s)
- Changyan He
- C He is with School of Mechanical Engineering and Automation at Beihang University, Beijing, 100191 China, and also with LCSR at the Johns Hopkins University, Baltimore, MD 21218 USA
| | - Niravkumar Patel
- N. Patel are with LCSR at the Johns Hopkins University, Baltimore, MD 21218 USA
| | - Iulian Iordachita
- I. Iordachita are with LCSR at the Johns Hopkins University, Baltimore, MD 21218 USA
| | - Marin Kobilarov
- M. Kobilarov are with LCSR at the Johns Hopkins University, Baltimore, MD 21218 USA
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32
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Savastano MC, Savastano A, Rizzo S. Pharmacological Adjuncts to Vitrectomy Surgery. Curr Pharm Des 2019; 24:4843-4852. [PMID: 30706802 DOI: 10.2174/1381612825666190130125136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 01/24/2019] [Indexed: 11/22/2022]
Abstract
Pharmacological adjuncts to vitrectomy surgery are useful tools to better deal with surgery. Their introduction has enriched the therapeutic choice before, during and after operations. Although several classifications could be made to frame adjuncts to vitrectomy, we preferred to divide the pharmacological adjuncts to vitrectomy surgery for therapeutic use in the pre-operatory procedure (neo-adjuvant), for intraoperative use and for post-operatory practice (adjuvant). This type of classification allowed us to explore all the adjuncts based on the timing of their use. The actual interest in vitrectomy surgery is giving rise to considerable interest in new molecules with and without the pharmacological effect that will soon be available for the aid of vitreoretinal surgery.
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34
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Innovative Vitreoretinal Surgery Technologies. Int Ophthalmol Clin 2018; 59:281-293. [PMID: 30585931 DOI: 10.1097/iio.0000000000000247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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35
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He C, Ebrahimi A, Roizenblatt M, Patel N, Yang Y, Gehlbach PL, Iordachita I. User Behavior Evaluation in Robot-Assisted Retinal Surgery. RO-MAN ... : THE ... IEEE INTERNATIONAL SYMPOSIUM ON ROBOT AND HUMAN INTERACTIVE COMMUNICATION : PROCEEDINGS. IEEE INTERNATIONAL SYMPOSIUM ON ROBOT AND HUMAN INTERACTIVE COMMUNICATION 2018; 2018:174-179. [PMID: 30906505 DOI: 10.1109/roman.2018.8525638] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Retinal microsurgery is technically demanding and requires high surgical skill with very little room for manipulation error. The introduction of robotic assistance has the potential to enhance and expand a surgeon's manipulation capabilities during retinal surgery, i.e., improve precision, cancel physiological hand tremor, and provide sensing information. However, surgeon performance may also be negatively impacted by robotic assistance due to robot structural stiffness and nonintuitive controls. In complying with robotic constraints, the surgeon loses the dexterity of the human hand. In this paper, we present a preliminary experimental study to evaluate user behavior when affected by robotic assistance during mock retinal surgery. In these experiments user behavior is characterized by measuring the forces applied by the user to the sclera, the tool insertion/retraction speed, the tool insertion depth relative to the scleral entry point, and the duration of surgery. The users' behavior data is collected during three mock retinal surgery tasks with four users. Each task is conducted using both freehand and robot-assisted techniques. The univariate user behavior and the correlations of multiple parameters of user behavior are analyzed. The results show that robot assistance prolongs the duration of the surgery and increases the manipulation forces applied to sclera, but refines the insertion velocity and eliminates hand tremor.
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Affiliation(s)
- Changyan He
- School of Mechanical Engineering and Automation at Beihang University, Beijing, 100191 China, and also with LCSR at the Johns Hopkins University, Baltimore, MD 21218 USA
| | - Ali Ebrahimi
- LCSR at the Johns Hopkins University, Baltimore, MD 21218 USA
| | - Marina Roizenblatt
- Wilmer Eye Institute at the Johns Hopkins Hospital, Baltimore, MD 21287 USA .,Federal University of Sao Paulo, São Paulo, 04023-062 Brazil
| | | | - Yang Yang
- School of Mechanical Engineering and Automation at Beihang University, Beijing, 100191 China
| | - Peter L Gehlbach
- Wilmer Eye Institute at the Johns Hopkins Hospital, Baltimore, MD 21287 USA
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Edwards TL, Xue K, Meenink HCM, Beelen MJ, Naus GJL, Simunovic MP, Latasiewicz M, Farmery AD, de Smet MD, MacLaren RE. First-in-human study of the safety and viability of intraocular robotic surgery. Nat Biomed Eng 2018; 2:649-656. [PMID: 30263872 DOI: 10.1038/s41551-018-0248-4] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Microsurgery of the retina would be dramatically improved by instruments that offer supra-human precision. Here, we report the results of a first-in-human study of remotely controlled robot-assisted retinal surgery performed through a telemanipulation device. Specifically, 12 patients requiring dissection of the epiretinal or inner limiting membrane over the macula were randomly assigned to either undergo robot-assisted-surgery or manual surgery, under general anaesthesia. We evaluated surgical success, duration of surgery and amount of retinal microtrauma as a proxy for safety. Surgical outcomes were equally successful in the robotic-surgery and manual-surgery groups. Differences in the amount of retinal microtrauma between the two groups were statistically insignificant, yet dissection took longer with robotic surgery (median time, 4 min 5 s) than with manual surgery (1 min 20 s). We also show the feasibility of using the robot to inject recombinant tissue plasminogen activator under the retina to displace sight-threatening haemorrhage in three patients under local anaesthesia. A safe and viable robotic system for intraocular surgery would enable precise and minimally traumatic delivery of gene therapy or cell therapy to the retina.
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Affiliation(s)
- T L Edwards
- Nuffield Laboratory of Ophthalmology, Department of Clinical Neurosciences, University of Oxford, Oxford, UK.,Oxford Eye Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - K Xue
- Nuffield Laboratory of Ophthalmology, Department of Clinical Neurosciences, University of Oxford, Oxford, UK.,Oxford Eye Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | | | | | - M P Simunovic
- Nuffield Laboratory of Ophthalmology, Department of Clinical Neurosciences, University of Oxford, Oxford, UK.,Oxford Eye Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - M Latasiewicz
- Oxford Eye Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - A D Farmery
- Nuffield Division of Anaesthetics, University of Oxford, Oxford, UK
| | | | - R E MacLaren
- Nuffield Laboratory of Ophthalmology, Department of Clinical Neurosciences, University of Oxford, Oxford, UK. .,Oxford Eye Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
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Admittance Control for Robot Assisted Retinal Vein Micro-Cannulation under Human-Robot Collaborative Mode. ICCAS ... : INTERNATIONAL CONFERENCE ON CONTROL, AUTOMATION, AND SYSTEMS. INTERNATIONAL CONFERENCE ON CONTROL, AUTOMATION, AND SYSTEMS 2018; 2017:862-866. [PMID: 29607442 DOI: 10.23919/iccas.2017.8204346] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Retinal vein occlusion is one of the most common retinovascular diseases. Retinal vein cannulation is a potentially effective treatment method for this condition that currently lies, however, at the limits of human capabilities. In this work, the aim is to use robotic systems and advanced instrumentation to alleviate these challenges, and assist the procedure via a human-robot collaborative mode based on our earlier work on the Steady-Hand Eye Robot and force-sensing instruments. An admittance control method is employed to stabilize the cannula relative to the vein and maintain it inside the lumen during the injection process. A pre-stress strategy is used to prevent the tip of microneedle from getting out of vein in in prolonged infusions, and the performance is verified through simulations.
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Roizenblatt M, Edwards TL, Gehlbach PL. Robot-assisted vitreoretinal surgery: current perspectives. ROBOTIC SURGERY (AUCKLAND) 2018; 5:1-11. [PMID: 29527537 PMCID: PMC5842029 DOI: 10.2147/rsrr.s122301] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Vitreoretinal microsurgery is among the most technically challenging of the minimally invasive surgical techniques. Exceptional precision is required to operate on micron scale targets presented by the retina while also maneuvering in a tightly constrained and fragile workspace. These challenges are compounded by inherent limitations of the unassisted human hand with regard to dexterity, tremor and precision in positioning instruments. The limited human ability to visually resolve targets on the single-digit micron scale is a further limitation. The inherent attributes of robotic approaches therefore, provide logical, strategic and promising solutions to the numerous challenges associated with retinal microsurgery. Robotic retinal surgery is a rapidly emerging technology that has witnessed an exponential growth in capabilities and applications over the last decade. There is now a worldwide movement toward evaluating robotic systems in an expanding number of clinical applications. Coincident with this expanding application is growth in the number of laboratories committed to "robotic medicine". Recent technological advances in conventional retina surgery have also led to tremendous progress in the surgeon's capabilities, enhanced outcomes, a reduction of patient discomfort, limited hospitalization and improved safety. The emergence of robotic technology into this rapidly advancing domain is expected to further enhance important aspects of the retinal surgery experience for the patients, surgeons and society.
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Affiliation(s)
- Marina Roizenblatt
- Department of Ophthalmology, Wilmer Eye Institute, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Ophthalmology, Federal University of São Paulo, São Paulo, Brazil,
| | - Thomas L Edwards
- Department of Clinical Neurosciences, University of Oxford, Royal Victorian Eye and Ear Hospital, Melbourne, VIC, Australia
| | - Peter L Gehlbach
- Department of Ophthalmology, Federal University of São Paulo, São Paulo, Brazil,
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Nuzzi R, Brusasco L. State of the art of robotic surgery related to vision: brain and eye applications of newly available devices. Eye Brain 2018; 10:13-24. [PMID: 29440943 PMCID: PMC5798758 DOI: 10.2147/eb.s148644] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Robot-assisted surgery has revolutionized many surgical subspecialties, mainly where procedures have to be performed in confined, difficult to visualize spaces. Despite advances in general surgery and neurosurgery, in vivo application of robotics to ocular surgery is still in its infancy, owing to the particular complexities of microsurgery. The use of robotic assistance and feedback guidance on surgical maneuvers could improve the technical performance of expert surgeons during the initial phase of the learning curve. Evidence acquisition We analyzed the advantages and disadvantages of surgical robots, as well as the present applications and future outlook of robotics in neurosurgery in brain areas related to vision and ophthalmology. Discussion Limitations to robotic assistance remain, that need to be overcome before it can be more widely applied in ocular surgery. Conclusion There is heightened interest in studies documenting computerized systems that filter out hand tremor and optimize speed of movement, control of force, and direction and range of movement. Further research is still needed to validate robot-assisted procedures.
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Affiliation(s)
- Raffaele Nuzzi
- Department of Surgical Sciences, Eye Clinic, University of Torino, Turin, Italy
| | - Luca Brusasco
- Department of Surgical Sciences, Eye Clinic, University of Torino, Turin, Italy
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Molaei A, Abedloo E, de Smet MD, Safi S, Khorshidifar M, Ahmadieh H, Khosravi MA, Daftarian N. Toward the Art of Robotic-assisted Vitreoretinal Surgery. J Ophthalmic Vis Res 2017; 12:212-218. [PMID: 28540014 PMCID: PMC5423376 DOI: 10.4103/jovr.jovr_63_17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
New technological progress in robotics has brought many beneficial clinical applications. Currently, computer integrated robotic surgery has gained clinical acceptance for several surgical procedures. Robotically assisted eye surgery is envisaged as a promising solution to overcome the shortcomings inherent to conventional surgical procedures as in vitreoretinal surgeries. Robotics by its high precision and fine mechanical control can improve dexterity, cancel tremor, and allow highly precise remote surgical capability, delicate vitreoretinal manipulation capabilities. Combined with magnified three-dimensional imaging of the surgical site, it can enhance surgical precision. Tele-manipulation can provide the ability for tele-surgery or haptic feedback of forces generated by the manipulation of intraocular tissues. It presents new solutions for some sight-threatening conditions such as retinal vein cannulation where, due to physiological limitations of the surgeon's hand, the procedure cannot be adequately performed. In this paper, we provide an overview of the research and advances in robotically assisted vitreoretinal eye surgery. Additionally the barriers to the integration of this method in the field of ocular surgery are summarized. Finally, we discuss the possible applications of the method in the area of vitreoretinal surgery.
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Affiliation(s)
- Amir Molaei
- Department of Electrical Engineering, K.N Toosi University of Technology, Tehran, Iran.,Department of Mechanical Engineering, Concordia University, Montreal, Canada
| | - Ebrahim Abedloo
- Department of Electrical Engineering, K.N Toosi University of Technology, Tehran, Iran
| | - Marc D de Smet
- MicroInvasive Ocular Surgery Center (MIOS sa), Lausanne, Switzerland.,Preceyes bv, Eindhoven, the Netherlands
| | - Sare Safi
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Milad Khorshidifar
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hamid Ahmadieh
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Narsis Daftarian
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Ocular Engineering Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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de Smet MD, Stassen JM, Meenink TCM, Janssens T, Vanheukelom V, Naus GJL, Beelen MJ, Jonckx B. Release of experimental retinal vein occlusions by direct intraluminal injection of ocriplasmin. Br J Ophthalmol 2016; 100:1742-1746. [PMID: 27688592 PMCID: PMC5256413 DOI: 10.1136/bjophthalmol-2016-309190] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 08/25/2016] [Accepted: 09/03/2016] [Indexed: 12/13/2022]
Abstract
PURPOSE Retinal vein occlusions (RVO) are a major cause of vision loss in people aged 50 years and older. Current therapeutic options limit the consequences of RVO but do not eliminate the cause. Cannulation of the involved vessel and removal of the clot may provide a more permanent solution with a less demanding follow-up. However, cannulation of smaller retinal veins remains challenging. This paper explores the use of ocriplasmin (recombinant plasmin without its kringles) to clear RVO, using a robotic micromanipulator. METHODS Branch RVO were induced in a porcine model with rose bengal followed by 532 nm endolaser to the superior venous branch of the optic nerve. The vein was cannulated proximal to the occlusion or beyond the first branching vessel from the obstruction. The vein was infused with a physiologic citric acid buffer solution (CAM) or CAM/ocriplasmin. The time of cannulation, number of attempts, and the ability to release the thrombus were recorded. RESULTS Cannulation and infusion was possible in all the cases. The use of a micromanipulator allowed for a consistent cannulation of the retinal vein and positional stability allowed the vein to remain cannulated for up to 20 min. In none of the attempts (5/5) with CAM did the thrombus dissolve, despite repeat infusion/relaxation cycles. In 7/7 injections of CAM/ocriplasmin near to the point of obstruction, the clot started to dissolve within a few minutes of injection. An infusion, attempted beyond the first venous branch point proximal to the clot, was unsuccessful in 2/3 attempts. CONCLUSIONS Ocriplasmin is effective in resolving RVO if injected close to the site of occlusion with the use of a micromanipulator.
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Affiliation(s)
- Marc D de Smet
- MicroInvasive Ocular Surgery Center (MIOS sa), Lausanne, Switzerland.,Preceyes nv, Eindhoven, The Netherlands
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