AAO LIVE: Robot-assisted procedures may be the future of MIGS

The American Academy of Ophthalmology is holding its 2022 annual meeting at McCormick Place in Chicago.

Investigators from the Icahn School of Medicine at Mount Sinai, New York, reported that robot-assisted microinterventional glaucoma surgery (MIGS) has potential for interventions in the anterior segment, according to Gautam Kamthan, MD, an assistant director of Ophthalmic Innovation and Technology at New York Eye and Ear Infirmary of Mount Sinai.

They reported the first such feasibility of robot-assisted ophthalmic gonio-surgery.

Kamthan and co-investigators studied the potential for use of this approach by comparing robotic interventions preclinically to the standard manual approach in synthetic eye models for MIGS.

Three robotic systems have been developed by the New York Eye and Ear Robotics Program: the µ-Robotic Gonio Surgery System, the T-Rex µ-Robotic Flexible Goniotomy, and iStent µ-Robotic Implantation System.

A comparison of the surgical precision between manual and surgical procedures speaks to the rationale for robotic-assisted procedure. Manual procedures are characterized by 100-µm tremor peak-to-peak vector magnitude, 500 to 1,000-mN human finger force sensing resolution, and 182-µm root mean square tremor amplitude with manual vitreoretinal surgery, Kamthan explained.

In contrast, robot-assisted surgical precision offers less than 5-µm precision tremor stabilization, 1 to 10-mN force-sensing smart instrumentation, and automated procedure-specific guidance and assistance with analytics.

In MIGS, robotics would enhance the safety and efficacy of the procedures. “Precision matters for small devices,” he emphasized.

In support of this, Ianchulev, professor of Ophthalmology, director of Ophthalmic Innovation and Technology at New York Eye and Ear Infirmary of Mount Sinai, noted that 30% of iStents (Glaukos) are malpositioned according to an FDA Safety Report.

The doctors used the nonimplantable goniotomy intervention in phase I of the study and trabecular stent implantation with the iStent inject W in phase II. The main outcome was anatomically successful goniointervention.

During the phase I segment, Kamthan reported that they performed consecutive trials of complete ab interno goniotomy robotically and manually for at least 90 degrees using a standard goniotomy knife. An ab interno goniotomy exceeding 150 degrees was achieved using the flexible, guided microinterventional goniotomy instrument.

During the phase II segment, the iStent inject W device was deployed successfully in 10 trials within the trabecular meshwork in all of the attempts both manually and robotically.

“A system for robot-assisted MIGS can successfully achieve interventions in the anterior segment,” the investigators concluded. “This is the first demonstration of the feasibility of robot-assisted ophthalmic gonio-surgery.”