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LABORATORY SCIENCE
Robot-assisted simulated cataract surgery
Tristan Bourcier, MD, PhD, Jimmy Chammas, MD, Pierre-Henri Becmeur, MD, Arnaud Sauer, MD, PhD,
David Gaucher, MD, PhD, Philippe Liverneaux, MD, PhD, Jacques Marescaux, MD, PhD, Didier Mutter, MD, PhD
Purpose: To evaluate the feasibility of robot-assisted simulated
cataract surgery.
Setting: Institut de Recherche Contre les Cancers de l’Appareil
Digestif, European Institute of Telesurgery, and Strasbourg Univer-
sity Hospital, Strasbourg, France.
Design: Experimental study.
Methods: Cataract surgeries were performed on a Kitaro cataract
wet-lab training system simultaneously using the Da Vinci Xi robotic
surgical system and the Whitestar Signature phacoemulsification
system. For each procedure, the duration and successful completion
of the surgery with or without ocular complications were assessed.
Results: Procedures were successfully performed on 25 lens nuclei.
The feasibility of robot-assisted simulated cataract surgery was
confirmed. The robotic surgical system provided the intraocular
dexterity and operative field visualization necessary to perform the
main steps of the phacoemulsification procedure; that is, corneal
incisions, capsulorhexis, grooving, cracking, quadrant removal, and
irrigation/aspiration of the ophthalmic viscosurgical device (OVD).
The intervention of a second surgeon was required for the
intraocular injections of OVD, balanced salt solution, and intraocular
lenses. The mean operative time was 26.44 minutes G5.15 (SD).
All lens nuclei were removed. Inadvertent enlargement of the main
corneal incision caused by the phaco handpiece was observed in
2 cases.
Conclusion: Experimental robot-assisted cataract surgery was
technically feasible using the new robotic surgical system combined
with a phacoemulsification machine.
J Cataract Refract Surg 2017; 43:552–557 Q2017 ASCRS and ESCRS
Online Video
Cataract surgery is the most widely performed surgi-
cal procedure in the world. Surgical techniques
have changed significantly over the past 50 years
to meet the growing level of expectations of surgeons
and patients. Recent advances in cataract surgery include
smaller incisions, more efficient phacoemulsification ma-
chines, femtosecond laser–assisted cataract surgery, and a
new generation of intraocular lenses (IOLs). Visual out-
comes are constantly improving in a safe, effective, pre-
dictable, and reproducible manner. Cataract surgery is
the archetype of quick, standardized, low-complication
surgery. As a consequence, a potential, exciting innovation
in cataract surgery might be the integration of surgical
robots.
1,2
Robot-assisted surgery has expanded over the past 20 years
in macrosurgical specialties (urological, general, digestive,
gynecological, cardiovascular); however, microsurgical
specialties, including ophthalmology, have seen little growth
in the field. The main reasons for this discrepancy include
that cataract surgeons work at a nearly robotic pace by
routinely performing up to 20 procedures per day; the
Da Vinci Robotic Surgical System (Intuitive Surgical, Inc.)
and the ARES Robot Auris Surgical Endoscopy System
(Auris Surgical Robotics), the only 2 surgical robots
approved by the U.S. Food and Drug Administration for
human surgery, are not specifically microsurgical robots;
and the cost of robotic systems might be prohibitive and
the learning curves for surgeons are potentially steep. There
are, nonetheless, potential advantages to the use of robotics
in eye surgery, including increased precision and maneuver-
ability of movements, scalability of motion, tremor filtration,
better ergonomics,task automation, and surgical training.
3–5
In addition, the use of robotics and the development of tele-
surgery for cataract surgery might be a good option in areas
Submitted: December 7, 2016 |Final revision submitted: February 3, 2017 |Accepted: February 20, 2017
From the Department of Ophthalmology (Bourcier, Chammas, Becmeur, Sauer, Gaucher), the Department of Digestive and Robotic Surgery (Mutter, Marescaux),
Institut de Recherche Contre les Cancers de l'Appareil Digestif–European Institute of Telesurgery (Marescaux, Mutter), Institut Hospitalo Universitaire, Institute of Image-
Guided Surgery (Bourcier, Marescaux, Mutter), New Civil Hospital, the Department of Hand Surgery (Liverneaux), Centre de Chirurgie Orthop
edique et de la Main,
Illkirch, Strasbourg University Hospital, and Equipe d’Accueil 7290 (Bourcier, Chammas, Gaucher), F
ed
eration de M
edecine Translationnelle de Strasbourg, University
of Strasbourg, Strasbourg, France.
Richard Bastier, Laurence Brisebard, Thomas Deroyon, Janel Hooven, Julien Lacaux, Gilles Lemoine, Eric Leplat, Olivier Moucheron, Association Alsacienne
d’Ophtalmologie, provided advice, proofreading, and technical support.
Corresponding author: Tristan Bourcier, MD, PhD, Department of Ophthalmology, New Civil Hospital, Strasbourg University Hospital, BP426, 67091 Strasbourg, France.
E-mail: tristan.bourcier@chru-strasbourg.fr.
Q2017 ASCRS and ESCRS
Published by Elsevier Inc.
0886-3350/$ - see frontmatter
http://dx.doi.org/10.1016/j.jcrs.2017.02.020
552
that lack ophthalmological infrastructures or surgeons.
6
As a
result, robotics might improve patient care and could well
become clinically relevant for cataract surgery in the future.
The Da Vinci Robotic Surgical System is the most
commonly used platform in human surgery. Four models
have been launched since 2001; they are the S, Si, Si HD,
and Xi. The Si model has been used in experimental condi-
tions to suture corneal lacerations in porcine eyes,
7
to
perform penetrating keratoplasties in porcine and cadaver
eyes,
8
and to remove foreign bodies, lens capsules (anterior
capsulorhexis), and vitreous in porcine eyes.
9
We recently
used the Si HD model to perform robot-assisted ocular sur-
face surgery (amniotic membrane transplantation and pte-
rygium surgeries) in a clinical setting.
10,11,A
The latest
version, Xi, has been on the market since 2014. One of
the improvements over the original system is the 8.0 mm
camera, which allows better visual definition and clarity
than the previous Si HD model. The camera has an autofo-
cus system and can be attached to any of the 4 arms as
needed.
This study evaluated the feasibility of robot-assisted
simulated cataract surgery using the new robotic surgical
system.
MATERIALS AND METHODS
Robot
The Da Vinci Xi surgical system consists of the following 3 com-
ponents: a mobile instrument cart with 4 articulated arms, a vision
cart, and a surgeon console used to control the robotic arms
(Figure 1).
12
The mobile cart contains the articulated robotic
arms, 3 of which carry surgical instruments and a fourth that ma-
nipulates the digital stereoscopic camera that allows the surgeon to
visualize the surgical field. The camera provides 3-dimensional
(3-D) vision with progressive magnification up to 15 times and
can be placed on any of the arms and autofocuses. Each of the
arms has multiple joints that allow 3-D movement of the surgical
instruments. The surgeon's console has an optical viewing system,
2 telemanipulation handles, and 5 pedals. The optical viewing
system has a 3-D high-definition view of the operating field and
displays text messages and icons that reflect the status of the sys-
tem in real time. The 2 telemanipulation handles allow remote
manipulation of the 4 articulated robotic arms. Master–slave con-
trols replicate the surgeon's hand motions, filtering tremor and
offering the possibility of using an adjustable motion-scaling ratio.
The following robotic tools were used for the surgical procedures:
ProGrasp forceps, Large SutureCut needle driver (needle driver 1),
and Mega SutureCut needle driver (needle driver 2) (all Intuitive
Surgical, Inc.).
Wet-Lab Phacoemulsification Procedure Model
The Kitaro wet-lab system (FCI Ophthalmics) was used to simu-
late cataract surgery. The artificial anterior segment includes a
cornea that provides a clear view of the anterior chamber and
a cataract nucleus made of clay. The artificial capsular bag is a
film made of red polyester. The cataracts are placed in a reusable
artificial sclera, and the wet-lab cornea is mounted on top. The
cornea has red markings for the main and side-port incisions.
Soft and medium nuclei densities were used for the experiments.
Phacoemulsification Machine
The Whitestar Signature phacoemulsification system (Abbott
Medical Optics, Inc.) was used. The phaco handpiece (Ellips FX)
as well as the irrigation/aspiration (I/A) handpiece were attached
with adhesive tape to the distal extremity of the robotic surgical
system forceps (Figures 2 and 3). The setting parameters were
the following: groove program, aspiration 28 cc/min, vacuum
85 mm Hg, and ultrasound (US) power 35 pps; quadrant program,
aspiration 33 cc/min, vacuum 445 mm Hg, and US power if
occluded 45 pps/unoccluded 15 pps; and I/A ophthalmic viscosur-
gical device (OVD) program, aspiration 34 cc/min and vacuum
505 mm Hg. Venturi and peristaltic modes were both used. The
wireless footpedal was installed at the right side of the surgeon's
console of the robotic system.
Non-Robotic Instruments
Three microsurgical tools were specifically prepared for the pro-
cedures. A single-use micromanipulator (MMSU1471, Malosa
Medical) was intentionally broken at the junction between the
shaft and the distal extremity. A cystotome was made using a
27-gauge bent-tipped disposable needle (Becton Dickinson and
Co.), and the plastic syringe-adaptor of the needle was removed.
A 2.2 mm keratome (Alcon Laboratories, Inc.) was prepared by
removing the metallic extremity from the plastic shaft.
Surgical Technique
An ophthalmic surgeon (T.B.) with experience in cataract surgery
and robotic microsurgery certified by the Robotic Assisted Micro-
surgical and Endoscopic Society performed the surgical proced-
ures. Surgical movements were scaled to 1.5:1. The camera was
installed vertically above the eye on arm 2. A superior single-
plane 2.2 mm main corneal incision was created with the keratome
held by needle driver 1 (arm 4) (Figure 4)(Video 1, available at
http://jcrsjournal.org). The needle of the OVD syringe was intro-
duced into the anterior chamber using needle driver 1. With the
Figure 1. Remote console of the robotic surgical system. The sur-
geon's console is equipped with an optical viewing system, 2 tele-
manipulation handles, and 5 pedals. The optical viewing system,
called the stereo viewer, provides a 3-D view of the operating field.
The 2 handles allow remote manipulation of the articulated robotic
arms. The phaco handpiece is controlled with the pedal installed
next to the robot's pedals.
553LABORATORY SCIENCE: ROBOT-ASSISTED CATARACT SURGERY
Volume 43 Issue 4 April 2017
needle in the correct position, an assistant was asked to push the
plunger of the syringe to inject sodium hyaluronate 1.41% (Healon
GV) and fill the anterior chamber. Flap creation and continuous
curvilinear capsulorhexis (CCC) were performed with the cysto-
tome held by needle driver 1.
The hydrodissection cannula (Alcon Laboratories, Inc.)
mounted on a 3 mL syringe filled with a balanced salt solution
was introduced under the anterior capsule using needle driver 1.
Once the hydroneedle was correctly positioned and held by arm
4, an assistant was asked to push the plunger to perform hydrodis-
section. The phaco handpiece held by arm 3 (forceps) was intro-
duced into the anterior chamber through the main corneal
incision. A few passes with the phaco tip were made to sculpt
the first groove. The secondary corneal incision was created with
the 2.2 mm keratome held by needle driver 2 (arm 4). It was
located approximately 60 degrees to the left of primary incision.
The micromanipulator held by arm 4 was introduced into the
anterior chamber and rotated the nucleus. A total of 4 grooves
were made with the phaco handpiece. A bimanual divide-and-
conquer fracturing technique was used to crack the nucleus inside
the capsular bag. Once the quadrants were removed, the anterior
chamber and the capsular bag were refilled with OVD as previ-
ously described. A preloaded single-piece IOL (Tecnis PCB00, Ab-
bott Medical Optics, Inc.) was injected through the main incision.
Once the extremity of the delivery system was positioned under
the cornea with arm 4, an assistant was asked to screw in the
plunger to insert the IOL into the capsular bag. The assistant visu-
alized the progression of the IOL using the screen control on the
vision cart. The surgeon controlled the unfolding and the place-
ment of the IOL within the capsular bag.
At the end of the procedure, the OVD was removed by the I/A
handpiece held by arm 4. For each procedure, the operative time
and successful completion of surgery with or without complica-
tions or unexpected events were assessed.
Outcome Measures
The primary endpoint of this study was the feasibility of a robot-
assisted simulated cataract surgery using the robotic surgical sys-
tem. The main outcome measure was the duration of each surgical
procedure from the creation of the main corneal incision to the
end of the OVD removal. The gold-standard procedure was
defined by appropriate-sized clear corneal incisions, OVD injec-
tion without corneal or capsule touch, a 5.0 to 6.0 mm CCC,
lens removal by the phacoemulsification handpiece without poste-
rior capsule rupture or endothelium touch, in-the-bag IOL inser-
tion, complete OVD removal, and sealed corneal incisions at the
end of the procedure.
RESULTS
Twenty-five procedures were performed at the Institut de
Recherche Contre les Cancers de l’Appareil Digestif center,
Strasbourg, France, between April and October 2016. The
feasibility of robot-assisted simulated cataract surgery was
confirmed. The robotic surgical system provided the dex-
terity and operative field visualization necessary to perform
the main steps of the phacoemulsification procedure (ie,
corneal incisions, capsulorhexis, grooving, cracking, quad-
rant removal, and I/A of the OVD). However, human
Figure 2. Installa tion. In the fore ground
is the phacoemulsification system. In
the intermediate plane is the surgical
table with the cataract wet-lab training
system installed with the robotic surgi-
cal system above it. In the background
is the surgeon's remote console.
Figure 3. The cataract wet lab. The wet lab is installed under the ro-
botic surgical system arms. The robot is equipped with 4 arms. Arm
1(left) holds suture cut needle driver 2. Arm 2 holds the camera. Arm
3 is equipped with a forceps attached to the phaco handpiece with
adhesive tape. Arm 4 holds suture cut needle driver 1. The next non-
robotic instruments to be held by the arms of the robot lie around the
artificial eye (keratome, cystotome, and micromanipulator tips).
554 LABORATORY SCIENCE: ROBOT-ASSISTED CATARACT SURGERY
Volume 43 Issue 4 April 2017
assistance was needed for the intraocular injections of
OVD, balanced salt solution, and IOLs. Moreover, specific
microsurgical instruments (micromanipulator, keratome,
and cystotome) and a phaco system had to be used in com-
bination with the robotic system.
The time required for docking the robot and the installa-
tion of the arms and instruments, the phacoemulsification
machine, and the wet-lab training system kit was 60 mi-
nutes. The time for preparation of the non-robotic instru-
ments, the phaco handpiece and I/A probe, the syringes,
and OVDs was approximately 10 minutes. Table 1 shows
the duration of performing the capsulorhexis, nucleus
removal, and the total procedure. All lens nuclei were
completely removed.
Inadvertent enlargement of the main corneal incision
caused by the phaco handpiece was observed in 2 cases.
The enlargements consisted of a 3.0 mm radialization of
the main corneal incision, which had a T-shape at the
end of the procedure. In these 2 cases, there was a sponta-
neous wound leak at the end of the procedure.
No radialization of the capsulorhexis was observed.
A perfectly round capsulorhexis was impossible to achieve
because a cystotome was used in absence of a specific cap-
sulorhexis forceps. However, all capsulorhexes were contin-
uous, measuring between 4.0 mm and 6.0 mm in diameter.
There were no cases of posterior capsule rupture or endo-
thelium touch during the procedures.
DISCUSSION
The question of the role of robotics in cataract surgery,
already minimally invasive microsurgery with excellent re-
sults, is legitimate. However, the inclusion of robots in sur-
gical platforms might be the next major advance in cataract
surgery.
We report the feasibility of robot-assisted simulated cata-
ract surgery using the Da Vinci Xi Surgical System in com-
bination with the Whitestar Signature phacoemulsification
system. Each step from corneal incision to IOL implanta-
tion was completed successfully. This is, to our knowledge,
the first use of the Xi model in experimental ocular surgery.
The Da Vinci is a master–slave surgical robot that enables
restitution of surgeons' movements with improved accuracy
(7 degree-of-freedom) through motion scaling and tremor
filtering. Although not specifically designed for eye surgery,
since 2006 the commercial availability of the robotic surgi-
cal system has led to many studies of its applicability in
anterior and posterior segment eye surgery.
7–9
Concerning
cataract surgery, the feasibility of performing capsulorhexis
was explored by Bourla et al.
9
using the Si model on enucle-
ated porcine eyes. However, the authors reported inadver-
tent tension on the ocular surface and the impossibility of
achieving a CCC. Moreover, poor visualization of the
Figure 4. Surgical sequences. A: The corneal incision is created with suture cut needle driver 1 holding a 2.2 mm keratome. B: The anterior
chamber is filled with OVD. C: The CCC is created with suture cut needle driver 1 holding a cystotome. Dand E: Phacoemulsification and frag-
ment removal is completed using the divide-and-conquer technique. F: A preloaded 1-piece IOL is injected through the main incision.
Table 1. Duration of certain surgical steps and the entire
procedure.
Step Mean (Min) ± SD Range
Capsulorhexis 4.60 G1.63 3.25, 9.62
Nucleus removal 7.36 G1.58 4.40, 11.8.53
Total procedure 26.44 G5.15 19.65, 46.28
555LABORATORY SCIENCE: ROBOT-ASSISTED CATARACT SURGERY
Volume 43 Issue 4 April 2017
operative field, limited maneuverability of the instruments,
and the absence of microsurgical instruments were consid-
ered hurdles to further investigations of the system.
Given the reservations concerning poor visualization, we
decided to perform experimental robot-assisted cataract sur-
gery using the Xi version because it provides magnification
and 3-D image quality close to those of modern surgical mi-
croscopes. The resolution of the image seen on the surgeon's
console is 1280 pixels 1024 pixels (SXGA standard). Thus,
visualization of the operative field was perfectly adequate for
intraocular surgery. It was easy to position the instruments at
the appropriate depth in the anterior chamber and nucleus.
With the camera lens, the surgeon can automatically focus
on the operative field when the distance between the arm
and the tissue is 34 G5 mm. The autofocus on the image
is practical and time saving. This is an advantage over con-
ventional operating microscopes and the previous Da Vinci
models.
Another reason for the good quality of visualization of the
operative field was the use of the Kitaro wet-lab system. This
training kit was introduced in 2010 by Akura to improve
phacoemulsification skills.
13
The artificial cornea in this sys-
tem provides a clear view of the lens without the corneal edema
that can be found in porcine eyes. Moreover, there is no vari-
ability caused by anatomic differences between samples. The
Kitaro kit offers a realistic experience but has 2 drawbacks
when compared with the use of porcine eyes. First, corneal in-
cisions offer more resistance than naturally encountered in pig
eyes. Second, the natural phenomenon of backlighting is ab-
sent and because the capsular bag is colored, there is no
need to search or use background lighting. This is an advantage
when using the Da Vinci Xi Surgical System because at present,
the system has no backlighting feature. The kit is therefore a
good model to practice and/or assess new surgical techniques,
such as robotic anterior segment surgery.
In the absence of specific ophthalmic instruments, we
used a macrosurgical Da Vinci forceps to hold modified
conventional instruments (micromanipulator, cystotome,
2.2 mm keratome) and the phaco and I/A handpieces.
With this modification, the new Xi model of the robotic
surgical system has the dexterity to perform the main steps
of the phacoemulsification procedure.
However, the Xi model still has several limitations for
intraocular surgery. The remote center of motion (ie, the
pivot point) is too proximal when compared with conven-
tional manual surgery, in which the surgeon directly handles
the instruments with his or her fingertips. The remote center
of motion is an important issue for ocular surgery assisted
with the Da Vinci system. This system has a remote center
of motion designed for laparoscopic surgery, which is far
from what is required for an eye. In addition, it has a me-
chanical remote center of motion that cannot be modified.
This absence of a stable, distal pivot makes intraocular ma-
neuvers less controllable. This drawback and the limited
range of motion of the phaco handpiece explain the
abnormal enlargement of the main corneal incision. Trans-
lational and vertical movements in the corneal wound
induced excessive mechanical forces on the cornea resulting
from the arm that held the phaco handpiece. For the same
reason (remote center of motion too far removed from the
cornea) and the absence of capsulorhexis forceps, it was
difficult and time consuming to create a perfectly round cap-
sulorhexis of the same diameter on all attempts. We hope
that research and development will improve the remote cen-
ter of motion. It is indeed a sine qua non condition to
consider intraocular surgery in a clinical setting.
The assistance of a second surgeon was needed for the
3 steps that required manual injections: hydrodissection of
the nucleus, OVDfilling of the anterior chamber and capsular
bag, and IOL implantation. Such assistance was also needed
to install the I/A handpiece on arm 4 at the end of the proced-
ures. Additional difficulties were the need for the main sur-
geon to create the non-robotic tools (micromanipulator,
cystotome, keratome) specific to the eye, the absence of a cap-
sulorhexis forceps, and the duration of the procedures.
Compared with Si or Si HD models, the high quality of
the optical system of the new Xi model makes experimental
cataract surgery feasible. However, at present its use in a
clinical setting is not practical because of the lack of specific
instruments and the precision of the machine.
Since the 1980s, many experimental prototypes of micro-
surgical robots dedicated solely to intraocular surgery have
been developed.
5
Most are lightweight master–slave telema-
nipulators that remotely reproduce the surgeon's movements
with high precision and a wide range of motion.
1
Most were
designed for retinal procedures (intravascular drug delivery,
posterior vitreous detachment, epiretinal membrane
peeling) and have been used in animal models. The intraoc-
ular robotic interventional surgical system is, to our knowl-
edge, the only prototype that can perform both anterior
segment and posterior segment surgeries. Construction of
a capsulorhexis and cortex removal with an I/A handpiece
were successfully performed in 4 porcine eyes.
2
The precision
and maneuverability also appeared to be excellent in poste-
rior segment surgery. This is a promising area of research.
We believe that a microsurgical robot will soon be available
for clinical use. The recent use of the PreceEye surgical robot
(a prototype developed by Eindhoven University of Technol-
ogy) to peel an epiretinal membrane in a patient proves that
clinical research progresses faster than what we expect.
B
The main hurdle for more widespread research into the
robot and its use in ophthalmic surgery might be its high
cost. Ophthalmic surgery is already very efficient, and
recent innovations such as femtosecond laser devices for
cataract surgery provide very good results with limited
costs. The robot must produce better results in terms of
safety or the reduction of adverse effects to justify the extra
cost. Another important obstacle is patient confidence,
which we believe will improve over time as new studies
show better final outcomes than with manual procedures.
In conclusion, we found that it is feasible to perform the
main steps of simulated cataract surgery using the Da Vinci
Xi robotic surgical system, the Whitestar Signature phaco-
emulsification system, and the Kitaro wet-lab kit, excluding
the injection phases. This is a new step toward robotic ante-
rior segment surgery. Both the magnification and quality of
556 LABORATORY SCIENCE: ROBOT-ASSISTED CATARACT SURGERY
Volume 43 Issue 4 April 2017
the 3-D image of the Da Vinci Xi system are close to those
of modern surgical microscopes. However, the current ki-
nematics of the robotic arms and the absence of specific
ophthalmologic instruments were found to be hurdles for
further clinical investigations. We believe that the next steps
in research will lead to several real improvements in robot-
assisted microsurgery, such as the development of specific
ophthalmologic instruments, increased precision, integra-
tion of ophthalmic lasers, augmented-reality imaging, and
artificial intelligence systems. These improvements will
allow surgeons to separate what today is considered a fan-
tasy; that is, fully robotic computer-aided automated cata-
ract surgery where surgeons assist robots.
WHAT WAS KNOWN
The inclusion of surgical robots in cataract platforms could
be the next major advance in cataract surgery.
Those in the field of cataract surgery, compared with other
surgical specialties, are still experimenting with robot-
assisted procedures.
WHAT THIS PAPER ADDS
It was feasible to perform all main steps of simulated cata-
ract surgery using the new robotic surgical system in
combination with a phacoemulsification system.
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Disclosures: None of the authors has a financial or proprietary in-
terest in any material or method mentioned.
First author:
Tristan Bourcier, MD, PhD
Department of Ophthalmology, New Civil
Hospital, Strasbourg University Hospital,
Strasbourg, France
557LABORATORY SCIENCE: ROBOT-ASSISTED CATARACT SURGERY
Volume 43 Issue 4 April 2017
