Ocular surgery stands on the cusp of revolutionary transformation, driven by rapid advancements in artificial intelligence (AI), robotics, virtual reality (VR), and evolving surgical imaging techniques. In the coming years, these innovations promise to reshape the landscape of ophthalmic surgery, offering unprecedented precision, efficiency, and personalized patient care for ambulatory surgery centers (ASCs) that have the wherewithal to adopt them.
“As we have witnessed in various industries—automotive, aviation, and banking, among others—the integration of novel technologies can transform and improve the human experience,” says Joseph Nathan, founder, president, and chief medical officer of Forsight Robotics in Yokneam Illit, Israel. “I believe that in the next decade, AI, surgical robotics, and other technological advancements will become inseparable from the ophthalmic surgery center.”
Artificial Intelligence: Let’s Be Real
Thanks to the significant growth of Big Data, it could be argued that the “smart transformation” of ophthalmic surgery has been well underway for quite some time, says Jeffrey Whitman, president and chief surgeon of Key-Whitman Eye Center in Dallas.
“Some people say, ‘I don't use AI.’ Well, if you use anything that’s computer generated and that looks at hundreds or thousands of cases and helps you decide how or what to do based on past learning, that’s AI,” Dr. Whitman says, citing AI-driven nomograms as one example.
In recent years, forms of artificial intelligence such as machine learning and deep learning have also been proven highly effective in the early screening and identification of patients with diabetic retinopathy, age-related macular degeneration, and other disorders. Early diagnosis facilitated by AI not only enhances treatment outcomes, but also allows for more effective planning, potentially preventing irreversible vision loss.
Last July, Intelligent Retinal Imaging Systems (IRIS) announced a partnership with AEYE Health for retinal imaging and diagnostics. Under the agreement, IRIS will license AEYE Diagnostic Screening (AEYE-DS), an FDA-cleared AI technology that autonomously detects diabetic retinopathy using only one image per eye. In an FDA clinical study, the AEYE-DS was found to have 93% sensitivity and over 91.4% specificity for more-than-mild diabetic retinopathy using one image per eye captured by the Topcon NW400 fundus camera.
Even smartphones can be used to detect diabetic retinopathy, macular degeneration, and other conditions in patients living in parts of the world who lack access to eye-care specialists. “Someone can put drops in a patient's eyes and dilate them, hold a phone camera up to the eye, take a picture, and send it to a screening center, where it goes through an AI algorithm to determine, ‘Is this likely to be diabetic retinopathy? Does this need treatment?’” Dr. Whitman says.
Research is also confirming the growing utility of AI-based algorithms in assessing refractive surgical candidates and determining intraocular lens (IOL) power. They are also being incorporated into femtosecond lasers for greater capsulorhexis precision based on the thickness and diameter of the IOL, as well as the locations of the front and back capsules, Dr. Whitman says.
“Think about that,” he says. “The most delicate part of cataract surgery is the capsulorhexis. The laser does it automatically, and it cuts the exact diameter that you want every time. [The laser] is in full control. I’ve done probably over 50,000 cataract surgeries, but can I do it as reproducibly as the computer can? No.”
Bots on the Ground
Just as it has in abdominal and orthopedic surgeries, robotic technology shows promise of bringing higher levels of accuracy, precision and safety to retinal and cataract surgeries. Horizon Surgical is working on a platform that combines visualization systems, machine learning, and micro-precision arms to provide surgeons with real-time visual and tactile feedback. ForSight Robotics is developing ORYOM, a surgical robotics platform that utilizes AI-based algorithms, advanced computer vision, and data analytics, to provide surgeons with “superior dexterity and real-time guidance,” says Dr. Nathan, noting that ORYOM is “ten times more precise” than a surgeon’s hand.
“Combined with robotics, AI technology will be able to utilize its ‘knowledge base’ to guide surgeons during every procedure,” says Dr. Nathan.
A Virtual "See Change"
Virtual reality simulations have long been a training ground for pilots, astronauts, golfers, and even surgeons in specialties such as neurology and orthopedics. They are now poised to radically change the training of ocular surgeons. VR platforms are already allowing trainees to hone their skills in a risk-free environment and are likely to become more widespread as the technology evolves.
“Before even entering the operating room, AI and ML algorithms, together with VR simulations, will be used to train future generations of ophthalmologists, ensuring that they have access to cutting-edge methods and techniques no matter where they are in the world,” says Dr. Nathan.
Dr. Whitman agrees. “I think virtual reality is the future of surgical training,” he says. “I learned how to suture on an orange peel, which wasn’t bad. But doing it through virtual reality will simulate it so much better that when [a new surgeon] comes to the real eye, he’ll already feel pretty good about doing it.”
Dr. Whitman adds that while porcine eyes are likely to remain a staple of training for the foreseeable future, VR simulations can make training more accessible and cost effective. “The problem is, you can only have so many pig eyes, because they do cost money, whereas in virtual reality, I can suture an eye 17 times in a row if I want to,” he says.
Virtual reality also promises to expand its reach in surgery itself. The Beyeonics One ophthalmic exoscope (BVI Medical), for example, is a lightweight, adjustable, augmented reality headset display and control unit that overcomes the constraints of microscopy and wall-mounted monitors, according to the company.
With the exoscope, head gestures control frequent functions like focus, zoom, pan and illumination, and are also used to toggle through various overlays. The device’s rotatable camera head consists of two ultra-high-resolution (>8K), low-noise cameras and LED illumination. The head is also capable of tilting, allowing for fixed OR setup with zero additional turnover time between right and left eye surgeries.
“I think eventually that will become [virtual reality’s] biggest use,” Dr. Whitman says. “It’s a 3D-vision headset that you wear, rather than looking through a microscope at all. You’re also not wearing 3D goggles to look at a screen to get the three-dimensional view. You’re able to see what you’re doing much better and more easily.”
Smile for the Camera
New imaging techniques are also paving the way to a future when traditionally clinic-based imaging tools, such as optical coherence tomography (OCT), are used during actual surgery. For example, incorporated into surgical microscopes, intraoperative OCT lets surgeons assess retinal structures with micron-level resolution in real time. The advantages to the capability are significant, Dr. Whitman says.
“If you can do an OCT at the same time you’re doing macular hole surgery, and [see that] you’ve cleared the area, you’ve removed the membrane over the macula, and the hole is resolving—knowing all that at the end of surgery, as opposed to waiting days or weeks afterwards, would be phenomenal. That can help make surgery better and may be more predictive of postsurgical outcomes,” he says.
Overcoming the Financial Hurdles
Integrating AI, robotics, VR, and other advanced technologies is likely to require significant financial resources. Add infrastructure and equipment upgrades; staff training; and compliance with state and federal regulations, and becoming an “ASC of the Future” is likely to be unaffordable—at least in the early going—for most facilities. This may be the case particularly for smaller ASCs operating in an environment of falling Medicare reimbursements, says Dr. Whitman.
“I get reimbursed X amount of dollars for doing a cataract surgery. If I decide to replace my microscope with a newer one that has a video overlay to help me know where to place and how to orient a toric lens, I don’t get any more reimbursement for replacing my microscope,” Dr. Whitman says. “Unless we get insurance to buy into it—to acknowledge that [these technologies] are safer, more reproducible, et cetera, it’s going to be difficult for the majority of surgeons to incorporate into their practice.”
Even today, Dr. Whitman says, only 30% to 40% of surgeons use femtosecond lasers, even though they were cleared for cataract surgery more than a decade ago. The same is similarly true of tools like Alcon’s Verion Digital Marker.
“I’ll bet you that less than 20% of ophthalmologists utilize it, because their ASCs are not going to pay for it. To me, that’s going to be the battle going forward: Can we afford something that, even if it’s better, is it better enough that it’s going to save us money?” he observes.
Despite such concerns, as their efficacy becomes apparent and their costs come down, the new tools and applications are likely to earn more widespread acceptance. “Growing demand from patients for cutting-edge solutions will drive surgeons to adopt intelligent tools faster,” Dr. Nathan says. Market forces are also likely to exert pressure on ASCs to keep up with competing hospital-based and ambulatory surgical centers.
“AI-based platforms, VR, surgical robotics, and other technologies that serve the surgeon and patient will significantly impact the quality … of ophthalmic surgeries that will be completed tomorrow,” Dr. Nathan says. “By embracing advanced technologies, surgeons can provide patients with the [best] clinical care while transforming their ophthalmology practices.” OASC
