Is the robot-assisted procedure the future of MIGS?

Image courtesy of New York Eye and Ear Infirmary of Mount Sinai.

Investigators from the Icahn School of Medicine at Mount Sinai, New York, United States, reported that robot-assisted microinterventional glaucoma surgery (MIGS) has potential for interventions in the anterior segment, according to Dr Gautam Kamthan, 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.

Dr 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 theNew York Eye and Ear Robotics Program: the µ-RoboticGonio Surgery System, the T-Rexµ-RoboticFlexible Goniotomy and iStentµ-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, Dr 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, Dr 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 1 of the study and trabecular stent implantation with the iStent inject W in Phase 2. The main outcome was anatomically successful goniointervention.

During the Phase 1 segment, Dr 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 2 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.

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