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A device designed to provide robotic assistance with micrometre precision in vitreoretinal surgery should enable surgeons to both improve the reproducibility and speed of existing procedures as well as develop treatments for diseases that have no adequate treatment today, according to Marc D de Smet MD, CM, PhD, FRCOphth.

“Vitreoretinal procedures have reached the limits of human precision movement. The micro-precision provided by this robotic device can facilitate research in new therapies for currently incurable diseases and can also help to reduce the learning curve for existing and new procedures and therapies. Furthermore, a well-operated integrated system could execute and speed up procedures such as vitrectomy, macular peeling or laser photocoagulation,” he said.

The device, developed by PRECEYES BV, was the recipient of first prize in the recent EURETINA Innovation Awards in London. Presenting the evolution of the PRECEYES system, Prof de Smet said it is the fruit of over 10 years’ research in collaboration with Eindhoven University of Technology, drawing on intelligent use of existing mechatronic components with clearly-defined parameters for optimal miniaturised components.

A prototype of the device has already been developed and successfully used in in vivo applications in animals, with research contracts with two major pharmaceutical companies underlining the feasibility and utility of the project, he said.

The advantages of using such a robotic system are multiple, said Prof de Smet. It can be used to automate certain steps of a typical VR procedure such as delivery of pan-retinal photocoagulation during surgery on a diabetic patient or it can be used as an assistive device.

In initial trials of the device, reproducibility tests show that the robotic system could provide an intrinsic precision of two to 10 microns, depending on the degree of freedom. This precision is calibrated at the tip of the instrument when positioned at the retina, which represents an improvement of 10 to 20 times compared to the human hand. As such, the system enables treatment of manually untreatable levels, he said.

“In addition to high precision, the device also enables us to filter out tremor, which is very useful for delicate VR surgery, and it is also possible to scale motion depending on the type of procedure you want to carry out with high precision,” said Prof de Smet.

The system was also designed to allow for instrument exchange, which is a major advantage in VR surgery, positional memory means that at each instrument change, you return to the exact same position you left when you decided to change instruments. In fact, you can maintain your sight on the surgical field and plan your next move as the instrument is being changed, according to Prof de Smet.

“It is very intuitive to use and it has excellent positional stability and memory. It does not replace the surgeon who continually monitors the surgical field inside the eye and performs manoeuvres with one hand as required. The system allows the surgeon to perform delicate procedures such as getting through very thin retina to inject fluid or cells, with much more precision and safety than is currently possible,” he said.

The possibility of automating individual steps within a vitreoretinal procedure is another major advantage of the system, said Prof de Smet. To illustrate the device’s precision, Prof de Smet showed in vivo images of a small vein of a porcine eye that was cannulated with a 20-micron cannula.

“The cannula is left in place and we inject fluid. There is an occlusion present that was created artificially. With the cannula in place, we can remove the occlusion and blood flow is re-established within a few minutes. The fact that we can cannulate such a small vein, when we typically have about 100 microns of physiologic tremor, and be able to leave it in place and not have to hold it while performing the fluid injection is a major advantage. We really think that will help improve and extend existing vitreoretinal procedures and allow new treatments to be developed,” he said.

Prof de Smet added that integration with 3-D digital imaging, intraoperative optical coherence tomography (OCT), and smart sensors will lead to the automation of precise procedures that will ultimately revolutionise the field. “Surgical dissection with a precision unheard of before, will be possible,” he said.

About 1.3 million vitreoretinal procedures are carried out worldwide every year in approximately 2,700 operating theatres, with a growth rate of four per cent per year, said Prof de Smet.

“At 1,000 vitreoretinal procedures a year per operating theatre, a PRECEYES system would add a cost of less than 60 euros per procedure. This would be financially attractive if it leads to five per cent more procedures through reduced theatre time, additional procedures for currently under-treated patients and use of smaller, less complex operating room facilities,” he said.

Prof de Smet pointed out, however, that the nature of breakthrough innovations means that the patient and financial benefits of the device have still to be proven in practice by clinical research.


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